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THE    TBANSACTIONS 


OF   THE 


EDINBURGH  OBSTETRICAL  SOCIETY 


THE  TRANSACTIONS 


EDINBURGH  OBSTETRICAL  SOCIETY. 


VOL.  XXXII. 


SESSION    1906-1907. 


EDINBURGH:    OLIVER    AND    BOYD, 

PUBLISHERS   TO   THE  SOCIETY 

19  0  7.  ^>/ 


PRINTED   BY   OLIVER   AND    BOYD,    TWEEDDALE   COURT     EDINBURGH. 


PREFACE 


This,  the  thirty-second  volume  of  the  Society's  Transactions, 
contains  a  record  of  its  proceedings  during  the  Session  1906-1907. 

In  it,  as  in  former  volumes,  the  views  brought  forward  in  the 
Papers  are  to  be  considered  as  those  of  the  writers  themselves, 
and  not  as  those  of  the  Society  as  a  body. 

The  Editor. 


October  1907. 


%\ 


EDINBURGH    OBSTETRICAL    SOCIETY. 


OFFICE-BEAKEKS  FOE  SESSION  1906-1907. 


|)rtsibent. 
JOHN  WILLIAM  BALLANTYNE,  M.D.,  F.R.C.P.Ed. 

©uc-|^rcsibtnts. 

DAVID  BERRY  HART,  M.D.,  F.R.C.P.Ed. 
WILLIAM  FORDYCE,  M.D.,  F.R.C.P.Ed. 

([Treasurer. 
WILLIAM  CRAIG,  M.D.,  F.R.C.S.Ed.,  71  Bmntsfield  Place. 

£ecrd  aries. 
JAMES  LAMOND  LACKIE,  M.D.,  F.R.C.P.Ed.,  1  Randolph  Crescent. 
GEORGE  FREELAND  BARBOUR  SIMPSON,  M.D.,  F.R.C.S.Ed.,  F.R.C.P.Ed., 

50  Melville  Street. 

librarian. 

FRANCIS  WILLIAM  NICOL  HAULTAIN,  M.D.,  F.R.C.P.Ed., 

12  Charlotte  Square. 

Cbitor  of   ^Transactions. 
ANGUS  MACDONALD,  M.B.,  F.R.C.S.Ed.,  27  Manor  Place. 

$Vtcmbcrs  of   Council. 
ALEXANDER  HUGH  FREELAND  BARBOUR,  M.D.,  F.R.C.P.Ed. 
NATHANIEL  THOMAS  BREWIS,  M.D.,  F.R.C.P.Ed.,  F.R.C.S.Ed. 
JAMES       HAIG      FERGUSON,       M.D.,       F.R.C.P.Ed.,        F.R.C.S.Ed., 

M.R.C.S.Eng. 
JOHN  MARTIN  MUNRO  KERR,  M.B.,  CM.,  Glasgow. 
Professor     Sir     JOHN      HALLIDAY     CROOM,      M.D.,     F.R.C.S.Ed., 

F.R.  C.P.Ed. 
SAMUEL  SLOAN,  M.D.,  F.F.P.  &  S.Glas.,  Glasgow. 
WILLIAM  MACRAE  TAYLOR,  M.B.,  F.R.C.S.Ed. 
EDWARD  WILLIAM  SCOTT  CARMICHAEL,  M.D.,  F.R.C.S.Ed. 


List    of    Presidents,    Vice-Presidents,    Treasurers, 
Secretaries,   and    Librarians  of  the  Society. 


PRESIDENTS. 

Year. 

Year. 

Dr  William  Beilby,      . 

1840-41 

Sir  A.  R.  Simpson, 

1882-83 

Sir  James  Y.  Simpson,  Bart. 

1842-57 

Dr  John  Connel 

1884-85 

Dr  John  Moir,     . 

1858-59 

Sir  J.  Halliday  Croom, 

1886-87 

Dr  Alex.  Keiller, 

1860-61 

Dr  C.  E.  Underhill,     . 

1888-89 

Dr  T.  H.  Pattison,       . 

1862-63 

Dr  D.  Berry  Hart, 

1890-91 

Dr  T.  Graham  Weir,    . 

1864-65 

Sir  A.  R.  Simpson, 

1892-93 

Sir  James  Y.  Simpson,  Bart. 

1866-67 

Dr  A.  H.  Freeland  Barbour, 

1894-95 

Dr  John  Burn,    . 

1868-69 

Dr  Alexander  Ballantyne, 

1896-97 

Dr  Charles  Bell,  . 

1870-71 

Sir  J.  Halliday  Croom, 

1898-99 

Dr  L.  R.  Thomson, 

1872-73 

Dr  R.  Milne  Murray,    . 

1900-01 

Dr  Matthews  Duncan, 

1874-75 

Dr  James  Ritchie, 

1902-03 

Sir  A.  R.  Simpson, 

1876-77 

Dr  N.  T.  Brewis, 

1904-05 

Dr  David  Wilson, 

1878-79 

Dr  J.  W.  Ballantyne,  . 

1906 

Dr  Angus  Macdonald, 

1880-81 

Sir  J.  Y.  Simpson,  Bart.. 
Dr  Alex.  Ziegler, 
Dr  J.  Cowan,  R.K, 
Dr  Fairbairn, 
Dr  Charles  Ransford, 
Dr  R.  B.  Malcolm, 
Dr  Charles  Bell,  . 
John  Kennedy,  Esq., 
Dr  John  Moir,     . 
Dr  T.  H.  Pattison, 
Dr  Beilby,  . 
Dr  T.  Graham  Weir, 
Dr  R.  B.  Malcolm, 
Dr  John  Moir,     . 
Dr  T.  Graham  Weir, 
Dr  John  Moir, 
Dr  W.  dimming, 
Dr  A.  Thomson,  . 
Dr  T.  H.  Pattison, 
Dr  David  Wilson, 
Dr  T.  Graham  Weir, 
Dr  George  S.  Keith, 
Dr  T.  Graham  Weir, 
Dr  Alex.  Keiller, 
Dr  T.  H.  Pattison, 
W.  S.  Carmichael,  Esq. 
Dr  John  Burn.     . 
Dr  Charles  Bell,  . 
Dr  William  Bryce, 
Dr  J.  A.  Sidey,    . 
Dr  William  Menzies, 
Dr  L.  R.  Thomson, 
Sir  A.  R.  Simpson, 
Dr  J.  Matthews  Duncan, 
Dr  Angus  Macdonald, 
Dr  R.  Peel  Ritchie,      . 


VICE-PRESIDENTS. 

.  Year. 
1840-41 
1840-41 
1842 
1842 
1843 
1843 
1844 
1844 
1845-47 
1845-47 
1848 
1848 
1849-53 
1849-53 
1854-55 
1854-55 
1856-57 
1856-57 
1858-59 
1858-59 
1860-61 
1860-61 
1862-63 
1862-63 
1864-65 
1864-65 
1866-67 
1866-67 
1868-69 
1868-69 
1870-71 
1870-71 
1872-73 
1872-73 
1874-75 
1874-75 


Year. 

Dr  James  Young, 

1876-77 

Dr  Alex.  Milne,   . 

1876-77 

Dr  R.  Peel  Ritchie,      . 

1878-79 

Dr  Angus  Macdonald, . 

1878-79 

Sir  A.  R.  Simpson, 

1880-81 

Dr  Robert  Bruce, 

1880-81 

Dr  James  Carmichael,  . 

1882-83 

Sir  J.  Halliday  Croom, 

1882-83 

Dr  Angus  Macdonald,  . 

1884 

Dr  Charles  E.  Underhill, 

1884-85 

Dr  William  Ziegler, 

1885 

Sir  A.  R.  Simpson, 

1886-87 

Dr  Leith  Napier, 

1886 

Dr  D.  Berry  Hart, 

1887-88 

Dr  James  Foulis, 

1888-89 

Dr  A.  J.  Sinclair, 

1889 

Sir  A.  R.  Simpson, 

1890 

Dr  Peter  A.  Young,     . 

1890-91 

Dr  John  Playfair, 

1891-92 

Dr  Freeland  Barbour,  . 

1892-93 

Dr  A.  Ballantyne, 

1893-94 

Dr  James  Ritchie, 

1894-95 

Sir  J.  Halliday  Croom, 

1895-96 

Sir  A.  R.  Simpson, 

1896-97 

Dr  R.  Milne  Murray,  . 

1897-98 

Dr  N.  T.  Brewis, 

1898-99 

Dr  J.  W.  Ballantyne,  . 

1899-1900 

Dr  Samuel  Macvie, 

1900-1901 

Dr  F.  W.  N.  Haultain, 

1901-1902 

Dr  J.  Haig  Ferguson,  . 

1902-1903 

Sir  A.  R.  Simpson, 

1903-1904 

Professor  J.  A.  C.  Kynoch.  . 

1904-1905 

Sir  J.  Halliday  Croom, 

1905-1906 

Dr  D.  Berry  Hart, 

1906-1907 

Dr  William  Fordyce,    . 

1907 

vili            LIST   OF   OFFICE-BEARERS 

AND   HONORARY   FELLOWS. 

TREASURERS.* 

Year. 

Year. 

Dr  Ransford, 

1840  to  1842 

Dr  J.  A.  Sidey,     . 

1859  to  1867 

Dr  G.  Paterson,     . 

1842  to  1847 

Dr  James  Young, 

1867  to  1875 

Dr  Cumming, 

1847  to  1854 

Dr  William  Craig, 

1875 

Dr  Keiller,   . 

1854  to  1859 

SECRETARIES. 

Year. 

Year. 

Dr  Ransford, 

1840  to  1842 

Dr  Alexander  Milne,     . 

1873  to  1875 

Dr  G.  Paterson,    . 

1840  to  1847 

Dr  C.  E.  Underhill,       . 

1875  to  1879 

Dr  Dunsmure, 

1842  to  1847 

Dr  James  Carmichael,    , 

1875  to  1881 

Dr  Cumming, 

1847  to  1854 

Dr  D.  Berry  Hart, 

1879  to  1883 

Dr  Keith,     . 

1847  to  1849 

Dr  A.  H.  Freeland  Barbour, 

1881  to  1886 

Dr  J.  M.  Duncan, 

1849  to  1852 

Dr  R.  Milne  Murray,     . 

1883  to  1889 

Dr  Keiller,    . 

1852  to  1859 

Dr  N.  T.  Brewis,  . 

1886  to  1893 

Dr  J.  A.  Sidey,     . 

1854  to  1861 

Dr  J.  W.  Ballantyne,    . 

1889  to  1896 

Dr  A.  R.  Simpson, 

1859  to  1865 

Dr  F.  W.  N.  Hauitain, 

1893  to  1897 

Dr  Peter  Young,  . 

1861  to  1863 

Dr  J.  Haig  Ferguson,   . 

1896  to  1901 

Dr  W.  Stephenson, 

1863  to  1867 

Dr  William  Fordyce,     . 

1897  to  1904 

Dr  R.  Peel  Ritchie, 

1865  to  1873 

Dr  Lamond  Lackie, 

1901 

Dr  G.  Stevenson  Smith, 

1867  to  1871 

Dr  Barbour  Simpson,    . 

1904 

Dr  James  Andrew, 

1871  to  1875 

LIBRARIANS. 

Year. 

Year. 

Dr  J.  Jamieson,    . 

1875  to  1879 

Dr  R.  Milne  Murray,     . 

1889  to  1899 

Dr  C.  E.  Underhill,       . 

1879  to  1883 

DrF.  W.  N.  Hauitain, 

1899 

Dr  Peter  Young,  . 

1883  to  1889 

EDITORS    OF    TRANSACTIONS. 

Year. 

Year. 

Dr  J.  W   Ballantyne,  . 

1896  to  1*99 

Dr  J.  Lamond  Lackie,  . 

1901  to  1905 

Dr  N.  T.  Brewis, 

1899  to  1901 

Dr  Angus  Macdonald,  . 

1905 

LIST  OF 

FELLOWS 

OF  THE  SOCIETY. 

HONORARY    FELLOWS. 


1898  Atthill,  Lombe,  M.D.,  Monkstown 
Castle,  Co.  Dublin. 

1897  Bantock,  Dr  George  Granville,  14 
Upper  Hamilton  Terrace,  Lon- 
don, N.W. 

1901  Bar,  Prof.  Paul,  M.D.,  Rue  la 
Boetie,  122,  Paris. 

1906  Bossi..  Professor  L.  M.,  The 
University,  Genoa. 

1886  Bozeman,  Dr  Nathan,  296  Fifth 
Avenue,  New  York. 


1901  Chrobak,  Professor  R.,  University  of 

Vienna. 
1898  Coe,  Prof.  Henry  C,  M.D.,  27  East 

Sixty-fourth  St.,  New  York. 
1898  Cullingworth,    Charles    J.,    M.D., 

D.C.L.,  14  Manchester  Square, 

London,  W. 
1898  Doyen,    E.,    M.D.,     LL.D.,    Rue 

Piccini,  6,  Paris. 
1882  Emmet,  Dr,  93   Madison    Avenue, 

New  York. 


*  Previous  to  1861  the  office  of  Treasurer  was  conjoined  with  that  of  Senior  Secretary. 


LIST   OF   FELLOWS. 


IX 


1900  Fehling,  Professor  Herman,  M.D.,  1 1901 

Kaiser    Wilhelm's    University, 
Strassburg. 
1882  Freund,  Emeritus    Professor    W.,  1 1902 
Kleiststrasse,  5,  Berlin. 

1901  Fritsch,    Prof.     H.,    University    of  1895 

Bonn. 

1902  Garrigues,  Prof.  H.  J.,  Tryon, North   1898 

Carolina. 

1891  Gusserow,  Prof.,  Charite,  Berlin.        1903 
1882  Hegar,  Professor,  Albert  Ludwig's 

University,  Frieburg.  1882 

1898  Kelly,    Prof.    Howard    A.,    M.D., 

Johns  Hopkins  Hospital,  Balti-    1903 
more,  U.S.A. 
1907  Kinoshita,  Dr  Seichu,  Professor  of  1906 
Obstetrics  and  Gynaecology,  Im- 
perial University,  Tokio,  Japan.    1905 

1892  Koeberle,  Dr  Eugene,  Strassburg. 
1898  Leopold,   Prof.   G.,  M.D.,   Seminar 

Strasse,  25,  Dresden.  1901 

1906  Makieyeff,      Professor      Alexander 

Matvejevic,     The     University,  |  1876 

Moscow. 
1895  Martin,    Prof.    Dr  A.,   N.    Greifs- 

wald.  1905 

1903  Morisani,  Professor  O.,  San  Felice    1897 

a  Piazza  Dante,  10,  Naples. 
1892  Miiller,     Professor     Peter,     Berne 

Switzerland. 
1889  Olshausen,  Professor,  Frauenklinik 

Artillerie  Strasse,  13,  Berlin. 


Ott,  Professor  D.  von,  M.D.,  Pro- 
fessor of  Obstetrics,  University 
of  St  Petersburg. 

Pestalozza,  Professor,  Instituts 
Obstetrico     Policlinico,    Roma. 

Pinard,  Professor  A.,  Rue  Cam- 
baceres,  10,  Paris. 

Pozzi,  ProfessorS.,  M.D.,  Hopital 
Broca,  Paris. 

Schauta,  Professor,  Kochgasse,  16, 
Vienna. 

Schultze,  Professor  B.  S.,  Univer- 
sity, Jena. 

Segond,  Dr  Paul,  Quai  d'Orsay, 
Paris. 

Simpson,  Emeritus  Prof.  Sir  Alex. 
R.,  LL.D.,  52  Queen  St. 

Sinclair,  Prof.  Sir  William  Japp, 
Garvock  House,  Dudley  Road, 
Manchester. 

Sneguireff,  Professor  W.,  University 
of  Moscow. 

Turner,  Principal  Sir  W.,  K.C.B., 
LL.D.,  D.C.L.,  6  Eton  Terrace, 
Edinburgh. 

Veit,  Professor,  University,  Halle. 

Williams,  Sir  John,  Bart.,  M.D., 
LL.D.,  Plas  Llanstephan,  Car- 
marthenshire. 

Winckel,  Prof.  Von,  Ludwig-Maxi- 
milian's  University,  Munich. 

Zweifel,  Professor,  Frauenklinik 
University,  Leipzig. 


CORRESPONDING     FELLOWS. 


1884  Arnott,  Brig.  Surg. -Lieut. -Col.  Jas., 
8  Rothesay  Place. 

1887  Baumgartner,  Dr  H.  S.,  Newcastle- 

on-Tyne. 
1892  Beilby,  Dr  J.  H.,  Bromsgrove. 
1863  Belgrave,  Dr,  Sydney. 

1888  Bentley,  Dr  Arthur  J.,  Cairo. 
1880  Bosch,  Dr  Van  Den,  Liege. 
1880  Brock,  Dr  W.  J.,  Edinburgh. 

1863  Brown,  Dr  R.  C,  Preston. 

1887  Chepmell,  Dr  C.  W.  J.,  London. 
1894  Curatulo,  Prof.  G.  E.,  Rome. 

1869  Davies,  Mr  Thos.,  Manchester. 
1873  Donovan,  MrW.,  Birmingham. 

1877  Engelmann,  Dr  G.,  Kreuznach. 
1896  Eyres,  Hugh,  Richmond. 

1864  Finlay,  Right  Hon.  Sir  R.  B.,  M.D  , 

LL.D.,  K.C.,  London. 


1883  Fraser,  Dr  Dyce,  London. 

1892  Fraser,  Dr  Hugh  E.,  Dundee. 

1879  Glaister,  Prof.,  Glasgow. 
1877  Grassett,  Dr  F.,  Toronto. 

1868  Grenser,  Dr  Paul  W.  T.,  Dresden. 

1864  Greve,  Dr,  Norway. 

1875  Groesbeck,   Dr  Hermann  J.,    New 

York. 
1897  Gunsberg,  Charkow,  Russia. 

1853  Hall,  Dr  D.,  Montreal. 

1870  Haynes,  Dr  Stanley  L.,  Malvern. 

1880  Helme,  Dr  J.  M.,  Carnforth. 
1885  Helme,  Dr  T.  A.,  Manchester. 

1865  Henderson,  Dr  E.,  China. 

1893  Howard-Jones,  Dr  J.,  Newport. 
1887  Hume,  Dr  T.,  Surgeon-Major,  India. 

1881  Hurst,  Dr  George,  Australia. 

1882  Husband,  Dr  H.  Aubrey,  Manitoba. 

1893  Hutchison,  Dr  Robert,  London. 

1894  Jennings,  Dr  David  D.,  New  York. 


LIST   OF   FELLOWS. 


1871  Johnston,  Dr  A.  C,  R.N.,  London. 

1882  Johnston,  Sur.-Maj.  Wilson,  India. 

1845  Keith,  Dr  George  S.,  Currie. 
1867  Kingston,  Dr,  Montreal. 
1874  Kleinwachter,  Prof.  L.,  Gratz. 

1871  Lambert,  Dr,  Paris. 

1887  Limont,  Dr  J.,  Newcastle-on-Tyne. 

1867  Lord,  Dr  Richard,  London. 

1878  Macdougall,  Dr  John  A.,  Cannes. 

1879  Machattie,  Dr  Thomas  A.,  Australia. 
1862  Mackay,  Dr  M.  A.,  Canada. 

1870  M'Kendrick,  Prof.,  Stonehaven. 
1869  M'Millan,  Dr  T.  L.,  Australia. 
1879  Marshall.  Dr  Thomas,  London. 
1866  Martin,  Dr  Karl,  Berlin. 

1860  Milburn,  Dr  George,  London. 

1883  Mills,  Dr  B.  Langley,  India. 
1897  Minchin,  Dr,  Charkow,  Russia. 

1861  Mitchell,  Sir  Arthur,  LL.D.,  Edin- 

burgh. 
1877  Moolman,  Dr  Henry,  South  Africa. 
1869  Mossop,  Mr  Isaac,  Bradford. 

1884  Neve,  Dr  E.  F.,  Kashmir. 
1849  Norris,  Mr  H.,  Petherton. 


1857  Parker,  Dr,  Nova  Scotia. 

1869  Paton,  Dr  J.  W.,  Bath. 

1885  Puckle,  Dr  S.  Hale,  Bishop's  Castle. 

1880  Reid,  Dr  James  More,  Aldershot. 

1878  Serdukoff,  Dr  A.,  St  Petersburg. 

1887  Shiels,  Dr  G.  F.,  San  Francisco. 

1870  Smith,  Dr  D.,  Montrose. 
1890  Smith,  Dr  William,  America. 
1861  Stephenson,  Prof.  W.,  Aberdeen. 

1888  Stevenson,    Sir    Edmond  Sinclair, 

Cape  of  Good  Hope. 
1854  Storer,  Dr  H.,  Boston,  U.S.A. 
1875  Sutugin,  Dr  V.,  St  Petersburg. 

1867  Thomson,  Mr  W.,  Wrenbury. 
1880  Turner,  Dr  William,  Gibraltar. 

1885  Underhill,  Dr  F.  T.,  Vancouver. 
1861  Veale,  Dr  H.  R.  L.,  London. 

1864  Whiteford,  Dr  James,  Greenock. 

1886  Whitton,  Dr  A.  B.,  Aberchirder. 

1865  Wollowicz,     Dr     C,     St   Peters- 

burg. 


ORDINARY    FELLOWS. 


ARRANGED   CHRONOLOGICALLY. 

Note.— Those  marked  with  an  asterisk  have  been  Members  of  Council.    Members  of  Council 
continue  in  office  two  years. 

Date  of 
Admission. 

1866 
1867 
1867 
1867 
1868 
1868 
1869 
1870 

1870 
1870 
1870 
1871 
1871 
1872 
1873 
1875 

1875 


10 


15     * 


Thomas  John   Fordyce    Messer,    M.D.,    F.F.P.  &  S.  Glasg., 
Garelochhead,  ...... 

John  Charles  O^ilvie  Will,  M.D.,  CM.,  Aberdeen,      . 

William  Spalding.  M.D.,  M.R.C.S.  Eng.,  Gorebridge,  . 

George  Dickson,  M.D.,  F.R. C.S.  Ed.,  . 
♦James  Andrew,  M.D.,  F.R.C.P.  Ed.,  . 
*William  Taylor,  M.D.,  F.R.C.P.  Ed.,  . 

James  Ormiston  Affleck,  M.D.,  F.R. C.S.  Ed.,  F.R.C.P.  Ed.,  . 

William  Craig,  M.D.,  F.R, C.S.  Ed.,  . 
'♦Professor   Sir   John    Halliday   Croom,    M.D.,    F.R.C.S.  Ed., 

F.R.C.P.  Ed., 

'♦Alexander  Ballantyne,  M.D.,  F.R.C.P.  Ed.,  Dalkeith, 

William  Borwick  Robertson,  M.D.,  L.R.C.S.  Ed.,  London,      . 
'♦James  Carmichael,   M.D.,  F.R.C.P.  Ed., 
'*Peter  Alexander  Young,  M.D.,  F.R.C.P.  Ed.,  . 
'♦Charles  Edward  Underhill,  M.B.,  P.R.C.P.  Ed.,  F.R.C.S.  Ed., 
'♦John  Play  fair,  M.D.,  F.R.C.P.  Ed.,  Hon.  F.R.  C.S.  Ed., 
'♦Henry  Macdonald  Church,  M.D.,  F.R.C.P.  Ed., 

James  Lindsay  Howison  Herbert  Porteous,  M.D.,  F.R.C.S.  Ed., 
M.R. C.P.Ed.,  New  York     . 


LIST   OF   FELLOWS. 


XI 


Archibald  Bleloch,  M.B.,  Sc.D., 

Joshua  John  Cox,  M.D.,  F.R.C.S.  Ed.,  Eccles,  Manchester, 

20         *Thomas  Rutherford  Ronaldson,  M.B.,  F.R.C.P.  Ed.,    . 

Charles  H.  Thatcher,  F.R.C.S.  Ed.,      . 

*John  Brown  Buist,  M.D.,  F.R.C.P.  Ed., 

George  Herbert  Bentley,  L.R.C.P.  &  S.Ed.,  Kirkliston, 

Andrew  Douglas  Ramsay  Thomson,  F.R.C.P.  Ed.,  Musselburgh 

25  James   Stitt   Thomson,    M.D.,    F.R.C.P.Ed.,    F.R.C.S. Ed., 

Lincoln,         ...... 

John  Archibald,  M.D.,  F.R.C.S.  Ed.,  Bournemouth,    . 
*****David  Berry  Hart,  M.D.,  F.R.C.P.  Ed., 
♦David  Menzies,  M.B.,  F.R.C.S.  Ed.,     . 
Donald  Roderick  Morrison  Murray,  M.B.,  CM.,  Leith, 
30  Robert  Spence,  M.B.,  CM.,  Burntisland,       •  . 

George  Mackay,  M.B.,  F.RCS.  Ed.,     . 
James  Henry  Croudace,  L.R.C.P.  &  S.  Ed.,  Stafford,    . 
Alexander  Dinsey  Leith  Napier,  M.D.,  M.R.  C.P.L.,  Australia 
John  M'Watt,  M.B.,  CM.,  Duns, 
35        *  William  Nicol  Elder,  M.D.,  L.R.C.P.  &  S.  Ed., 

Henry  Hay,  M.B.,  CM.,  .... 

Abraham  Wallace,  M.D.,  F.F.P.  &  S.  Glasg.,  London, 
*John  Rogerson  Hamilton,  M.D.,  CM.,  Hawick, 
George  Roth  well  Adam,  M.D.,  CM.,  Melbourne, 
40*****Alexander  Hugh  Freeland  Barbour,  M.D.,  F.R.C.P.  Ed., 
James  Murray,  M.B.,  CM.,       .  .  . 

Andrew  James  Duncan,  M.D.,  L.R.CS.  Ed.,  Dundee, 
T.  Edgar  Underhill,  M.D.,  F.R.C.S.  Ed.,  Barnt  Green, 
♦* William  Loudon  Reid   M.D.,  F.F.P.  &  S.  Glasg.,  Glasgow, 
45  ****James  Ritchie,  M.D.,  F.R.C.S.  Ed.,  F.R.C.P.  Ed.,       . 
William  Alexander  Finlay,  M.D.,  F.R.C.S.  Ed.,  Trinity, 
James  More,  M.D.,  M.R.C.S.  Eng.,  Rothwell,  Kettering, 
Thomas  Rennie  Scott,  M.D.,  CM..  Musselburgh, 
♦George  Hunter,  M.D.,  F.R.C.S.  Ed.,  F.R.C.P.  Ed.,     . 
50  John  E.  Ranking,  M.D.,  F.R.C.P.L.,  M.R.C.S.  Eng.,  Tun 

bridge  Wells,  ..... 

♦Arthur  Douglas  Webster,  M.D.,  F.R.C.P.  Ed.,  . 
William  Haig  Brodie,  M.D.,  F.R.C.S.  Eng.,  M.R.CP.Lon. 
London,         ...... 

James  Hewetson,  M.B.,  CM.,  Hohnfield,  Reigate, 
♦♦Samuel  MacYie,  M.B..  CM..  Chirnside, 
55  John  Waugh,  M.D.,  CM.,  London, 

Hugh  Logan  Calder,  M.D.,  F.F.P.  k  S.  Glasg., 
Henry  Anderson  Peddie,  M.B.,  CM.,     . 

Thomas  Fisher  Gilmour,  L.R.C.P.  Ed.,L  F.P.  &  S.  Glasg. ,  Lslay 
Andrew  Stark  Carrie,  M.D.,  M.R.C.S.  Eng.,  London,  . 
60  William  Black  Alexander,  L.F.P.  &  S.  Glasg., 

Harry  George  Deverell,  M.D.,  CM.,     . 
♦George  Keppie  Paterson,  M.B.,  F.R.C.P.Ed.,  . 
Herbert  R.  Rendell,  M.B.,  CM.,  St  John's,  Newfoundland, 
David  Smart,  M.B.,  CM.,  Liverpool,  . 
65     ♦♦♦Nathaniel  Thomas  Brewis,  M.B.,  F.R.C.P.  Ed.,  F.R.C.S.  Ed 
*John  William  Ballantvne,  M.D.,  F.R.C.P.  Ed., 
Thomas  Proudfoot,  M.B.,  F.R.C.P.  Ed., 
W.  Fraser  Macdonald,  M. B.,  CM.,  Glasgow,  . 
William  Spence,  M.B.,  CM.,  Dollar,  . 
70  William  Wright  Millard,  M.B.,  CM., 

John  Mowat,  M.D.,  CM., 

James  Lumsden  Bell,  M.B.,  CM.,  Driffield,  Yorkshire, 
*Thomas  Brown  Darling,  M.D.,  CM.,   .  ,  , 


Date  of 
Admission. 
1876 
1876 
1876 
1876 
1877 
1877 
1877 

1877 
1877 
1877 
1877 
1878 
1878 
1878 
1878 
1878 
1879 
1879 
1879 
1879 
1879 
1879 
1879 
1879 
1879 
1879 
1880 
1880 
1880 
1880 
1880 
1881 

1881 
1881 

1881 
1881 
1881 
1881 
1882 
1882 
1882 
1882 
1882 
1882 
1882 
1882 
1882 
1883 
1883 
1884 
1884 
1884 
1884 
1884 
1884 
1884 


Xll 


LIST   OF   FELLOWS. 


*Harry  Melville  Dunlop,  M.D.,  F.R.C.P.  Ed.,     . 
75         *  Robert  William  Felkin,  M.D.,  London. 

James  K.  King,  M.D.,   Watkins,  New  York,    . 

William  Marshall,  L.R.C.S.  Ed.,  Milnathort,   . 

Fourness  Barrington,  M.B.,  F.R.C.S.  Eng.,  Sydney,  Australia 
•Francis  William  Nicol  Haul  tain,  M.D.,  F.R.C.P.  Ed., 
80        *John  Struthers  Stewart,  L.K.C.  P.  &  S.Ed.,      . 

Frederick  Anastasius  Saunders,  F.R.C.S.  Ed.,  L.R.C.P.  Ed. 
Grahamstown,  South  Africa, 

John  Smith,  M.D.,  M.R.C.S.  Eng.,  Kirkcaldy, 

William  Gayton,  M.D.,  M.R.C.P.L.,  M.R.C.S.  Eng.,  London 

Gustave  Michael,  M.  B.,  CM.,  London, . 
85       ** James  Haig  Ferguson,  M.D.,  F.R.C.P.  Ed.,  M.R.C.S.  Eng. 
F.R.C.S.  Ed.,  ..... 

John  Edward  Gemmell,  M.B.,  CM.,  Liverpool, 

Robert  Stewart,  M.B.,  CM.,     .  .  . 

Surgeon-Captain  Robert  Charles  Macwatt,  M.B.,  B.Sc,  CM. 
7th  Bengal  Cavalry,  Bombay 
*E.  H.  Lawrence  Oliphant,  M.D.,  CM.,  Glasgow, 
90  James  Hogarth  Pringle,  M.B.,  F.R.C.S.  Eng.,  Glasgow, 

John  Walton  Hamp,  L.  F. P.  &  S.  Glasg.,  L.S.  A. ,  Wolverhampton 

James  Auriol  Armitage,  M.  D. ,  C  M. ,   Wolverhampton, 

William  Henry  Miller,  M.D.,  F.R.C.P.  Ed.,      . 

John  M'Call,  L.R.C.P.  Ed.,  Portobello, 
95        *Thomas  Wood,  M.D.,  CM.,      .... 

Hugh  M'Callum,  L.R.C.P.  &S.  Ed.,  Kinloch-Rannoch, 

Nutting  Stuart  Fraser,  M.B.,  M.R.C.S.  Eng.,  St  John's,  New 
foundland,     ...... 

Augustus  Alexander  Matheson,  M.D.,  F.R.C.P.  Ed.,    . 

Robert  Mackenzie,  M.D.,  CM.,  Nairn, 
100        Thomas  Jackson  Thyne,  M.B.,  F.R.C.P.  Ed.,  . 

Ernest  T.  Roberton,  M.D.,  M.R.C.S.  Eng.,  New  Zealand, 
•Samuel  Sloan,  M.D.,  F.F.P.  &  S.  Glasg.,  Glasgow, 

James  Wm.  Fox,  L.R.C.P.  &S.  Ed.,  Southampton, 

John  Frederick  Sturrock,  M.B.,  CM.,  Broughty -Ferry, 
105         Alexander  Primrose,  M.B.,  M.R.C.S.  Eng.,  Toronto,  Canada, 

Arthur  Per igal,  M.D.,  M.R.C.S.  Eng.,  New  Barnet,  Herts, 

James  Aitken  Clark,  M.B.,  CM., 

Edward  Carmichael,  M.D.,  F.R.C  P.  Ed., 

Charles  Clark  Teacher,  M.B.,  CM.,  North  Berwick     . 
110         Robert  Inch,  M.B.,  CM.,  Gorebridge,  . 

Ellis  Thomas  Davies,  M.D.,  M.R.C.S.  Eng.,  Liverpool, 

John  Orr,  M.B.,  CM.,  Eccles,  Lancashire, 
•George  Owen  Carr  Mackness,  M.D.,  CM.,  Broughty -Ferry, 

Francis  Joseph  Baildon,  M.B.,  CM.,  Sotcthport, 
115        Surgeon-Lt.  Ralph  H.  Maddox,  M.B.,  M.R.C.S.  Eng.,  I.M.S 
Bengal,         ...... 

James  Williamson  Martin,  M.D.,  F.R.C.P.  Ed.,  Dumfries, 

James  Andrew  Blair,  M.D.,  CM.,  D.Sc,  Newcastle-on-Tyne, 
•John  Thomson,  M.D.,  F.R.C.P.  Ed.,    . 

Robert  Kirk,  M.D.,  F.R.C.S.  Ed.,  Bathgate,     . 
120       *  William  Fraser  Wright,  M.B.,  CM.,  Leith,      . 

Richard  Joseph  Tristan,  L.R.C.P.  &  S.  Ed.,  Retford,  Notts, 

Robert  Henry  Blaikie,  M.D.,  F.R.C.S.  Ed.,      . 

James  Hutcheson,  M.D.,  F.R.C.S.  Ed.,    . 

A.  A.  Jervis  Pereira,  M.D.,  Delag^a  Bay, 
125         Christopher  Martin,  M.B.,  F.R.C.S.  Eng.,  Birmingham 

John  George  Havelock,  M.D.,  CM.,  Montrose, 

JohnPirie,  M.B.,  CM. 


Date  of 
Admission. 

1884 
1884 
1884 
1884 
1884 
1884 
1884 

1885 
1885 
1885 
1885 

1885 
1885 
1885 

1885 
1885 
1886 
1886 
1886 
1886 
1886 
1886 
1887 

1887 
1887 
1887 
1887 
1887 
1887 
1887 
1887 
1887 
1887 
1887 
1887 
1887 
1887 
1887 
1887 
1887 
1887 

1887 
1887 
1887 
1887 
1887 
1887 
1887 
1888 
1888 
1888 
1888 
1888 
1888 


LIST   OF   FELLOWS. 


Xlll 


135 


140 


145 


150 


155 


160 


165 


170 


175 


180 


James  Gibson  Graham,  M.B.,  CM.,  Glasgow,  . 

Robert  Adams  Brewis,  M.D.,  CM.,  Dursley,    . 

John  Allison,  M.D.,  CM.,  Kettering,  Northampton,    . 

Archibald  Cowan  Guthrie,  M.B.,  CM., 

Samuel  Beatty,  M.B.,  CM.,  Pitlochry, 

Professor  James  Chalmers  Cameron,  M.D.,  Montreal,  . 

Albert  Edward  Morison,  M.B.,  F.R.CS.  Ed.,  M.R.CS.  Eng. 

West  Hartlepool,       ..... 
George  H.  Temple,  M.B.,  CM.,  Weston-super-Mare,  . 
Norman  L.  Boxill,  M.B.,  CM.,  Barbados, 
John  Hunter  Helm,  M.B.,  CM.,  Jiatho, 
George  Scott  MacGregor,  M.D.,  CM.,  Glasgow, 
William  Sneddon,  M.B.,  CM.,  Cupar-Fife,      . 
Thomas  Watts  Eden,  M.B.,  CM.,  London, 

*  William  Fordyce,  M.D.,  F.R.CP.  Ed., 

Charles     E.     Harvey,    M.B.,     M.R.CS.  Eng.,    Sav-la-Mar 
Jamaica,       .  ... 

Alexander  Lang  Murray,  L.R.CP.  &  S.  Ed.,  Australia, 
*GeorgePirrie  Boddie,  M.B.,  CM.,        .  . 

James  F.  W.  Ross,  M.  1).,  Toronto,  Canada, 
Hugh  Jamieson,  M.D.,  CM.,    .... 

Thomas    Wm.    Nassau     Greene,     L.R.CP.  Ed.,    L.R.CS.I 
Dublin,       ...... 

Prof.  John  Clarence  Webster,  M.D.,  F.R.CP.  Ed.,  Chicago, 

*  William  George  Aitchison  Robertson,  M.D.,  F.R.CP.  Ed., 
William  Basil  Orr,  M.D.,  CM., 

*  Edward  Farr  Armour,  M.B.,  CM.,        . 
George  Wilkinson,  M.D.,  CM.,  Liverpool, 

*  James  Lamond  Lackie,  M.D.,  F.R.CP.  Ed.,    . 
James  Wilson,  M.B.,  C.M.,        .... 
Archibald  Maclean,  M.D.,  CM.,  Kilmarnock, 
Frederick  William  Lyle,  M.D.,  CM.,  London, 
Thomas  Dobson  Poole,  M.D.,  CM.,  Liuthwaite, 
Charles  Newberry  Cobbett,  M.D.,  CM.,  Alberta, 
Alexander  William  Gordon  Price,  M.B.,  CM., 

Hugh  Shapter  Robinson,  M.R.CS.  Eng.,  L.R.CP.  Ed.,  London 
*George  Matheson  Cullen,  M.D.,  CM., 

Frederick  Albert  L.  Lockhart,  M.B.,  CM.,  Montreal,  Canada 

Edmund  Frederick  Tanney  Price,  M.B.,  CM., 

Ernest  Theophilus  Roberts,  M.D.,  CM.,  Keighley, 

Owen  Foulkes  Evans,  M.D.,  CM.,  Liverpool,  . 

James  Duncan  Farquharson,  M.B.,  CM.,  Newcastle- on-  Tyne, 

Harvey  Littlejohn,  M.B.,  F.R.CS.  Ed., 

Robert  Wise,  M.D.,  CM.,  London, 

William  Russell,  M.D.,  F.R.CP.  Ed., 

Alexander  Scott  Duncan,  M.B.,  CM.,  Polton, 

Prof.  William  Keiller,  F.R.CS.  Ed.,  Galveston,  Texas,  U.S.  A 
*Michael  Dewar,  M.D.,  CM.,     . 

Gains  T.  Smith,  M.D.,  Moncton,  New  Brunswick, 

John  Hugh  Alexander  Laing,  M.B.,  CM., 

Robert  Thin,  M.B.,  F.R.CP.  Ed., 

Alexander  Henry  Vassie,  M. B.,  CM.,  London, 

James  Harvey,  M.D.,  CM., 

Alexander  Henderson,  M.B.,  CM., 

James  Smith,  M.D.,  CM., 

George  Balfour  Marshall,  M.D.,  CM.,  Glasgow, 

William  Booth,  F.R.CS.  Ed.,    . 

Richard  T.  Yoe,  M.D.,  Louisville,  Kentucky,  U.S.A., 

Alexander  Bruce  Giles,  M.D.,  CM.. 


Date  of 
Admission. 
1888 
1888 
1888 
1888 
1888 
1888 

1888 
1888 
1888 
1888 
1888 
1888 
1888 
1888 

1889 
1889 
1889 
1889 
1889 

1889 
1889 
1889 
1889 
1889 
1889 
1889 
1889 
1890 
1890 
1890 
1890 
1890 
1890 
1890 
1890 
1890 
1890 
1890 
1890 
1890 
1890 
1890 
1890 
1890 
1891 
1891 
1891 
1891 
1891 
1891 
1891 
1891 
1891 
1891 
1891 
1891 


XIV 


LIST   OF   FELLOWS. 


Hamilton  Graham  Langwill,  M.D.,  F.K.C.P.  Ed.,  Leith, 

185         Herbert  Ernest  Lee,  M.B.,  CM.,  Australia, 

Charles  Martin,  M.B.,  CM.,  Newton  A bbot,  . 
William  Murray  Cairns,  M.B.,  CM.,  Liverpool, 
Robert  Dundas  Helm,  M.D.,  CM.,  Carlisle,  . 
James  Thomas  Moore  Giffen,  F.R.C.S.  Ed.,  Chester,    . 

190         Frank  Dendle,  M.B.,  D.P.H.,  Islcworth, 

Frederick  Thomas  Anderson,  M.D.,  F.R.C.S.  Ed., 

Simson  Carstairs  Fowler,  M.  B.,  CM.,  Juniper  Green, 

Prof.  John  Alexander  Campbell  Kynoch,  M.B.,  F.R.C.P.  Ed. 

Dundee,       . 
Walter  John  Shaw,  M.B.,  CM.,  Cockburnspath, 

195        Robert  Stirling,  M.D.,  CM.,  Perth,     . 

William     Henry    Vickery,    F.R.C.S.  Eng.,    L.R.C.P.  Lond. 

Weston-super-Mare  .... 

William  Ramsay  Smith,  M.B.,  CM.,  Australia, 
Charles  Frederick  Ponder,  M.D.,  CM.,  Tasmania, 
John  Tod,  M.B.,  CM.,  Leith,  . 

200         George  Henry  Walter  Smith,  M.D.,  CM.,  Sydney,  Australia 
Charles  Croomhall  Easterbrook,  M.D.,  CM.,  Ayr, 
Walter  Petrie  Simpson,  M.  B.,  CM.,  Bathgate, 
*James  Ernest  Moorhouse,  M.D.,  CM.,  Stirling, 
D.  W.  Johnston,  F.R.C.S.  Ed.,  Johannesburg,  South  Africa, 

205         David  George  Davidson,  M.B.,  CM.,  . 

Allen  Thomson  Sloan,  M.D.,  CM.,       . 
Robert  Balfour  Graham,  F.R.C.S.  Ed., 
Albert  Frederic  Rosa,  M.D.,  CM., 
George  Benjamin  Mitchell,  M.B.,  CM, 

210         Henry  Robins,  M.D.,  Jamaica, 

Linn  J.  Schotield,  M.D.,  Warrensburg 

George  Morton  Wilcockson,  L.R.C.P.  &  S.  Ed.,  Reading 

John  MacRae,  M.D.,  CM.,  Murray  field, 

George  Wade,  M.D.,  CM.,  Melrose,     . 

215         Philip  Grierson  Borrowman,  M.D. ,  CM.,  Crieff] 

William  Herbert  Gregory,  M.D.,  CM.,  Beverley,  Forks, 
James  Gibson  Cattanach,  M.B.,  F.R.C.P.  Ed., 
Alexander  Maitland  Easterbrook,  M.B.,  CM.,  Gorebridge, 
Robert  William  Roberts,  L.R.C.P.  &  S.  Ed.,  North  Wales, 

220        Claude  Buchanan  Ker,  M.D.,  F.R.C.P.  Ed.,     . 
Charles  Alexander  Butchart,  M.B.,  CM., 
Frederick  Maurice  Graham,  F.R.C.S.  Ed.,  L.R.C.P.  Ed., 
Robert  Hoggan,  M.B.,  CM.,  Liberton, 
James  Livingstone  Thompson,  M. B.,  CM.,  Australia, 

225        John  Stevens,  M.D.,  F.R.C.P.  Ed.,      . 

Hugh  Lewis  Hughes,  L.R.C.P.  &  S.  Ed.,  Dowlais, 
Sylvaniis  Glanville  Morris,  M.D.,  CM.,  Mardy, 
Thomas  Easton,  M.D.,  CM.,  Southampton, 
David  Robertson  Dobie,  M.D.,  CM.,  Crieff,     . 

230         Gopal  Govind  Vatve,  M.D.,  Bombay,   . 

Robert  William  Beesley,  M.D.,  CM.,  Bolton,  . 
William  A.  Stephen,  M.D.,  CM.,  Loftus -in- Cleveland, 
William  Edward  Fothergill,  M.D.,  CM.,  Manchester, 
George  Sandi son  Brock,  M.D.,  CM.,  Rome. 

235       *John  Martin  Munro  Kerr.  M.B.,  CM 

John  Montgomery,  M.B.,  CM.,  Birmingham, 
*Robert  Cochrane  Buist,  M.D.,  CM.,  Dundee,  . 
Robert  Thomson  Ferguson,  M.B.,  CM.,  Anstruther, 
Angus  Vallance  MacGregor,  M.D.,  CM.,   West  Hartlepool, 

240        Charles  William  Donald,  M.D.,  F.R.C.S.  Ed.,  Carlisle, 


Leven,  Fife,     . 

,   Whitby, 

!  Mo.,  U.S.A.,  '. 


Date  of 
Admission. 
1891 
1891 
1892 
1892 
1892 
1892 
1892 
1892 
1892 

1892 
1892 
1892 

1892 
1892 
1892 
1892 
1892 
1892 
1892 
1892 
1892 
1892 
1893 
1893 
1893 
1893 
1893 
1893 
1893 
1893 
1893 
1893 
1893 
1893 
1893 
1894 
1894 
1894 
1894 
1894 
1894 
1894 
1894 
1894 
1894 
1894 
1894 
1894 
1894 
1894 
1894 
1894 
1895 
1895 
1895 
1895 
1895 


250 


255 


260 


265 


270 


275 


280 


285 


290 


295 


LIST   OF   FELLOWS.  XV 


Date  of 
Admission. 

John  Strutbers,  M.B.,  CM.,  TransJcei,  South  Africa,  .  1895 

B.  W.  Broad,  M.B.,  CM.,  Cardiff,       ....  1895 

Edwin  Hindmarsh,  M.B.,  CM., 'Bengal,  .  .  1895 

Patrick  Mackin,  M.D.,  F.R.CS.  Ed.,  New  Zealand,  .  .  1895 

G.  Edgar  Helme,  M.B.,  CM.,  Manchester,       .  .  .  1895 

Percy  Theodore  Hughes,  M.B.,  CM.,  Broomsgrove,     .  .  1895 

John  Hosack  Fraser,  M.B.,  F.R.CP.  Ed.,  Bridge  of  Allan,     .  1895 

Stewart  Grant  Ogilvy,  M.B.,  CM.,  Fauldhouse,  .  .  1895 

Thomas  Howard  Morgan,  M.  D.,  F.R.CS.  Ed.,  Queensland,  Aust.,  1895 

William  Macrae  Taylor,  M.B.,  F.R.CS.  Ed.,   .  .  .  1895 

David  James  Graham,  M.D.,  F.R.CP.  Ed.,      .  .  1895 

Walter  William  Chipman,  M.D.,  F.R.CS.  Ed.,  Montreal,  .  1895 

John  dimming,  M.D.,  F.R.CS.  Ed.,  F.R.CP.  Ed.,    .  .  1896 

Sol  Jervois  Aarons,  M.D.,  CM.,  London,         ...  .  1896 

Robert  Beveridge,  M.B.,  CM.,  Leith,  .  .  .  1896 

John  Anderson,  M.B.,  CM.,  Pitlochry,  .  .  .  1896 

Thomas  John  Burton,  M.D.,  CM.,  Australia,  .  .  1896 

Robert  Gordon  M'Kerron,  M.B.,  CM.,  Aberdeen,        .  .  1896 

Frederick  John  M'Cann,  M.D.,  M.R.C.P.L.,  London,  .  1896 

David  Robert  Taylor,  L.R.C P.  &  S.Ed.,  Ayton,  .  .  1896 

George  William  Simla  Paterson,  M.B.,  CM.,  .  .  .  1896 

Robert  Henry  Watson,  M.D.,  CM.,  Hamilton,  .  .  1896 

Thomas  Marshall  Callender,  M.D.,  CM.,  Sidcup,        .  .  1896 

Lewis  Grant,  M.D.,  CM.,  Neston,         ....  1896 

Robert  Robertson,  M.B.,  CM.,  .  ....  1897 

James  Wilkie,  L.R.C  P.  &  S.  Ed.,  Portobello,  ...  1897 

Andrew  Graham,  M.D.,  Currie,  ....  1897 

Roderick  Murdoch  Matheson,  M.D.,  F.R.CS.  Ed.,      .  .  1897 

*Robert     Jardine,      M.D.,     F.F.P.S.  Glasg.,     M.R.CS.  Eng., 

Glasgow,       .  .  .  .  .  .  .  1897 

Daniel  Charles  Edington,  M.D. ,  CM., Penrith,  .  .  1897 

John  Macmillan,  M.D.,  F.R.CP.  Ed.,  F.R.CS. Ed.,  .  .  1897 

Harold  Sherman  Ballantyne,  M.B.,  CM.,  Dalkeith,    .  .  1897 

Ernest  Edward  Porritt,  M.D.,  F.R.CS.  Ed.,  New  Zealand,     .  1897 

William  John  Garbutt,  M.B.,  CM.,  Birmingham,      .  .  1897 

Henry  John  Forbes  Simson,  M.B.,  F.R.CS.  Ed.,  London,      .  1897 

William  Alexander  Potts,  M.D.,  CM.,  Birmingham,  .  .  1897 

Angus  Macdonald,  M.B.,  F.R.CS.  Ed.,  .  .  .  1897 

Bernard  Samuel  Story,  M.D.,  F.R.CS.  Ed.,  New  Zealand,      .  1898 

Alexander  Macdonald,  M.B.,  F.R.CS. Ed., |      .  .  .  1898 

George  Robert  Livingston,  M.D.,  CM.,  Dumfries,       .  .  1898 

Charles  Carmichael  Forrester,  M.B.,  CM.,        .  .  .  1898 

William  Morrison  Milne,  M.B.,  CM.,  .  .  .  .  1898 

William     Joseph     Murphy     Barry,      M.D.,      M.R.CP.Ed., 

Penarth,        .  .  .  .  .  .  .  1898 

John  Christie  Forbes,  L.R.C. P.  &  S.  Ed.,  Liberton,      .  .  1898 

Alexander  Cruikshank  Ainslie,  M.D..  CM.,     .  .  .  1898 

Henry   Aylmer  Dumat,  M.D.,  F.R. C.P.Ed.,  Durban,  South 

Africa,  .  .  .  .  .  .  .  1898 

Gabriel  Maurange,  M.D.,  Paris,  ....  1898 

John  Thomas  Woodside,  L.R.C. P.  &  S.  Ed.,  Stewartstown,      .  1898 
George    Freeland    Barbour    Simpson,    M.D.,     F.R.CS.  Ed., 

F.R.CP.  Ed., 1898 

Alfred  Charles  Sandstein,  M.D.,  Ch.B.,  New  Zealand,  .  1898 

Alfred  Shearer,  M.B.,  Ch.B.,  Newtown,  N.   Wales,       .  .  1898 

John  Henry  Rhodes,  M.B.,  Ch.B.,  Kendal,      .  .  .  1898 

James  Duncan  Slight,  M.D.,  Ch.B.,  Leicester, .  .  .  1898 

Francis  John  Harvey  Bateman,  M.D.,  CM.,  London,  .  .  1898 

Robert  John  Johnston,  M.B.,  CM.,     .  .  .  .  1899 


XVI 


List  of  fellows. 


William  Bertie  Mackay,  M.  D. ,  Berivkk-on-  Tweed, 

Edward  William  Scott  Carmicliael,  M.D.,  F.R.C.S.  Ed.. 

James  Wilson  M'Brearty,  F.R.C.S.  Ed.,  L.R.CP.  Ed.,    New 
Zealand,      ...... 

George  Crewdson  Thomas,  M.D.,  CM.,  London, 
300        John  Eason,  M.D.,  F.R. C.P.Ed.,  Leith, 

William  John  Barclay,  M.D.,  F.R.C.S.,  Ed.,  New  Zealand, 

Frederick  Adolphns  Fleming  Barnardo,  M.B.,  Ch.B.,  India, 

Alexander  Dingvvell  Fordyce,  M.D.,  F.R.C.P.  Ed.,     . 

William  Thomas  Ritchie,  M.D.,  F.R.C.P.  Ed., 
305         Owen,  St  John  Moses,  M.D.,  CM.,  B.Sc,  Calcutta,    . 

Charles  Wakeham  Holmested,  L.R.CP.  &  S.  Ed.,  L.F.P.S 
Glasg.,  Tuxford,       ..... 

Donald  MacGregor,  M.D.,  CM.,  Jedburgh, 
*Harry  Oliphant  Nicholson,  M.D.,  F.R.C.P.  Ed., 

Thomas  Scott  Brodie,  M. B.,  CM.,   Wishaw,    . 
310        William  Hope  Fowler,  M.B.,  Ch.B.,     . 

John  Stanley  Manford,  M.B.,  B.S.,  Neivcastle-on-Tyne, 

Ogden  Watson  Ogden,  M.D.,  M.R.C.S.,  Newcastle-on-Tyne, 

John  Craig,  M.B.,  Ch.B.,  .... 

William  Hartley  Bunting,  M.D.,  F.R.C.S.  Ed.,  Birmingham, 
315         Theodore  Charles  Mackenzie,  M.B.,  Ch.B.,  Aberdeen,  . 

Donald  George  Hall,  M.B.,  M.R.C.S.  Eng.,  Sussex,    . 

Hugh  Corbett  Taylor  Young,  M.D.,  CM.,  Sydney, 

John  Boyd  Jamieson,  M.D.,  F.R.C.S.  Ed., 

Malcolm  M'Larty,  M.B.,  CM., 
320         Peter  Joseph  Henry  Ferguson,  M.B.,  CM., 

Frederick  Gardiner,  M.D.,  CM., 

George  Mackie,  M.  B.,  Ch.B.,  Malvern, 

Kenmure  Duncan  Melville,  M.D.,  Ch.B., 

John  Thomas  Dickie,  L.  R.  C  P.  &  S.  Ed. , 
325         William  Ernest  Frcst,  M.B.,  Ch.B.,     . 

Frederick  David  Simpson,  M.D.,  F.R.C.S.  Ed., 

Francis  Wilfrid  Harlin,  F.R.C.S.  Ed.,  L.R.CP.  Ed.,  Queens- 
land, ...... 

William  Darling,  M.B.,  F.R.C.S.  Ed., 

Robert  Macfarlane  Mitchell,  M.  B.,  F.R.C.S.  Ed.,  Australia, 
330        Malcolm  Campbell,  M.B.,  F.R.C.S.  Ed., 

James  Ramsay  Munro,  M. D. ,  Ch.B.,  Spalding, 

George  James  Rogerson  Carruthers,  M.B.,  Ch.B., 

Hilda  Maud  M'Farlane,  L.R.CP.  &  S.  Ed.,  Burntisland, 

George  Dickson,  M.D.,  CM.,     .... 
335         Elsie  Maud  Inglis,  M.B.,  CM., 

George  Robertson.  L  R.C.P.  &  S.  Ed.,  Dunfermline, 

John  Jeffrey,  M.B.,  F.R.C.S.  Ed.,  Jedburgh,    . 

John  Wishart  Kerr,  M.B.,  Ch.B.,  Glasgow, 

William    Harold    Graham    Aspland,    M.D.,  M.R.C.S.  Eng. 
China,  ...... 

340        William  Taylor  McArthur,  M.D.,  F.R.C.S.  Ed.,  California, 

Alexander  Waddel  Greenhorn  Clark,  M.B.,  CM., 

Henry  Overton  Hobson,  M.D.,  CM.,  London,. 

Robert    Patton  Ranken   Lyle,    M.D.,    Ch.B.,    Newcastle-on- 
Tyne,  ...... 

Frederick  William  Kerr  Tough,  L.R.CP.  &  S.  Ed.,  St  Helen' 
Junction,  Lancashire,        .... 
345         Robert  Ashleigh  Glegg,  M.D.,  Ch.B.,  Leith,    . 

Walter  Scott  Patton,  M.B.,  Ch.B.,  India, 

David  Whiteside  Maclagan,  M.B.,  Ch.B.,  New  Zealand, 

Kennedy  C  M'llwraith,  M.B.,  M.CP.  &  S.  Ont.,  Toronto, 


LIST   OF   FELLOWS. 


XV11 


350 


35  i 


360 


365 


370 


375 


380 


385 


390 


395 


400 


Robert  Alexander  John  Harper,  M.D.,  Ch.B.,  Dalkeith, 

William  Hogg  Prentice,  M.D.,  Ch.B.,  Pendleton, 

Alexander  Mowatt  Malcolmson,  M.D.,  Ch.B.,  Corstorphine, 

David  Albert  Callender,  M.  B. ,  Ch.  B. ,  Knutsford, 

Caleb  Williams  Saleeby,  M.D.,  Ch.B.,  London, 

John  Andrew  Douglas  Thompson,  Halesowen, 

John  Ligertwood  Green,  M. D.,  Ch.B., 

William  Sloss,  M.B.,  Ch.B.,  Australia, 

Charles  James  Hill  Aitken,  M.D.,  CM.,  Cape  Colony, 

E.  R.  Secord,  M.D.,  Ontario,    . 

F.  E.  Thompson,  M.D.,  Montreal, 
John  M 'Gibbon,  M.B.,  CM., 
Thomas  James  Thomson,  M.D.,  CM., 
Charles  Mowbray  Pearson,  M.B.,  Ch.B., 
Ewen  John  Maclean,  M.D.,  M.R.C.P.  Lond.,  Cardiff, 
James  William  Somerville,  M.D.,  CM.,  Galashiels, 
Alexander  Miller,  L.R.C.P.  Ed.,  L.F.P.S.  Glasg.,  Glasgow, 
Hugh  Faulkner,  M.B.,  Ch.B  ,  Banbury, 
Duncan  Macnab  Callender,  M.B.,  Ch.B.,  Lancaster, 
Robert  Cranston  Low,  M.B.,  Ch.B.,     . 
Benjamin  Philip  Watson,  M.B.,  Ch.B., 
John  Macdonald,  M.B.,  CM.,  Cupar-Fife,      . 
Mabel  Hardie,   M.  B. ,  Ch.  B, ,  Stockport, 
John  Sullivan,  M.B.,  Ch.B.,     . 
Charles  William  Somerville,  M.B.,  Ch.B.,  China, 
Frank  Mayes  Willcox,  M.B.,  CM.,       . 
John  Tennant,  M.B.,  CM.,  Scunthorpe, 
Alexander  Simpson  Wells,  M.B.,  F.R.CS.  Ed.,  Cape 
Andrew  Binny  Flett,  M.B.,  Ch.B., 
William    Henry   Eden    Brand,   F.R.CS.  Ed.,    L.R.C, 

Banchory,  .... 

Francis  Cavanagh,  M.B.,  Ch.B.,  Sheffield, 
Alfred  Lambre  White,  L.R.C.P.  &  S.  Ed.,  Manchester, 
Robert  Bathgate  Johnston,  L.R.C.P.  &  S.  Ed.,  Penrith 
William    Llewellyn    Jones,    M.D.,    F.R.CS.  Ed.,    Merthyr 

Tydvil,       ...... 

Robert  Wilson  Gibson,  M.D.,  F.R.CS.  Ed.,  Orton,    . 

Philip  Henry  Mules,  M.B.,  Ch.  B.,  New  Zealand, 

Andrea  Francis  Honyman  Rabagliati,  M.D. ,  Ch.B.,  Bradford 

Donald  Gregor  MacArthur,  M.D.,  CM.,  Aberfcldy,     . 

Henry  Martyn  Stumbles,  M.  B.,  Ch.B.,  Amble, 

Gilbert  John  Farie,  M.B.,  Ch.B.,  Bridge  of  Allan, 

Cameron  Robertson  Gibson,  M.B.,  Ch.B.,  Gretna, 

James  Mathieson  Kirkness,  M.D.,  Ch.B., 

Katherine  Jane  Stark  Clark,  M.D.,  Ch.B.,  D.P.H.,    . 

David  Halliday  Croom,  M.D.,  Ch.B.,   . 

Eleanor  Russell  Elder,  M.B.,  Ch.B.,  Leith,      . 

Robert  William  Johnstone,  M.D.,  Ch.  B., 

James  William  Keay,  M.D.,  Ch.B., 

Ivan  Cochrane  Keir,  M.D.,  Ch.B.,  Melksham,  . 

Alexander  Grant  Macdonald,  M.B.,  CM., 

Charles  John  Shaw,  M.D.,  Ch.B.,  Montrose,    . 

Frederick  Porter,  M.B.,  CM.,    .... 

Sherwin  Gibbons,  M.D.,  Los  Angeles, 

Russell  Gerald  William  Adams,  M.D. ,  Ch.B.,  New  Zealand, 

Duncan     Campbell      Lloyd      Fitzwilliams,      M.D.,     Ch.B, 

London,       . 
Clarence  Brian  Dobell,    M.B.,  M.R.C.S.  Eng.,    M.R.C.P.L, 

Cheltenham,  ..... 


Town 


P.Ed 


Date  of 
Admission. 
1901 
1901 
1901 
1901 
1902 
1902 
1902 
1902 
1902 
1902 
1902 
1902 
1902 
1902 
1902 
1902 
1902 
1902 
1902 
1902 
1902 
1902 
1902 
1902 
1902 
1902 
1902 
1903 
1903 

1903 
1903 
1903 
1903 

1903 
1903 
1903 
1903 
1903 
1903 
1903 
1903 
1903 
1903 
1903 
1903 
1903 
1903 
1903 
1903 
1903 
1904 
1904 
1904 

1904 

1904 


X.V111 


LIST   OF   FELLOWS. 


405 


410 


415 


420 


425 


430 


435 


440 


445 


450 


455 


460 


Hugh  Stevenson  Davidson,  M.B. ,  Ch.B., 

Andrew    Milroy    Fleming,     C.M.G.,     M.B.,     F.R.C.S.  Ed 

Rhodesia,     ..... 
Thomas  William  Edmondston  Ross,  M.B.,  Ch.B.,  Cardiff, 
John  Benjamin  Hellier,  M.D.,  M.R.C.S.  Eng.,  Leeds,  . 
John  Thomas  Williams,  M.  D. ,  Treharris, 
William  Brown,  M.B.,  Ch.B.,  Braemar, 
John  Hepburn  Lyell,  M.D.,  CM..  Perth, 
Henry  Hugh  Robarts,  M.D.,  Ch.B.,  Haddington, 
Thomas  Garnet  Stirling  Leary,  M.B.,  Ch.B.,  Australia, 
Robert  Balfour  Barnetson,  M.B. ,  Ch.B.,  Portobello,     . 
James  Lochhead,  M.D.,  Ch.B.,  Earlston, 
Arthur  Charles  Strain,  M.D.,  Ch.B.,   West  Hartlepool, 
Lewis  Beesly,  L.R. C.P.Ed.,  F.R.C.S.  Ed., 
James  Crawford  Gibb  Macnab,  M.B.,  F.R.C.S.  Ed.,  Dysart, 
Andrew  Alexander  Hall,  M.B.,  Ch.B.,  . 
Robert  William  Lessel  Wallace,  M.B.,  Ch.B.,  Bournemouth, 
Alfred  Thom  Gavin,  M.B.,  CM.,  Dunaskin,    . 
Alastair  MacGregor,  M.D.,  CM.,  Market  Harborough, 
Edmond  Frost,  M.D.,  CM.,  Eastbourne, 
Edith  Cochrane- Brown  Pitts,  M.B.,  Ch.B.,  New  Zealand, 
James  Brownlee,  M.D.,  Ch.B.,  Middlesbrough, 
William  Joseph  Maloney,  M.D.,  Ch.B.,  Cairo, 
Peter  M'Ewan,  M.B.,  Ch.B.,  Bradford, 
George  Douglas  Mathewson,  M.B.,  Ch.B., 
Henry  Grey  Brown,  M.B.,  Ch.B., 

Richard  James  Harley,  M.D.,  L.R.C.P.  &S.Ed.,  Murruyjirld 
Andrew  Fleming,  M.B.,  Ch.B.,  Corstorphine, 
Robert  William  Craig,  M.D.,  Ch.B.,  Ford, 
Henry  John  Dunbar,  M.D.,  Ch.B.,      . 

Richard  Alfred  Blake,  M.D.,  Ch.B.,  Pretoria,  South  Africa, 
John  Herbert  Gibbs,  F.R.C.S. Ed., 
Alice  Marion  Hutchison,  M.D.,  Ch.B., 
Barbara  Martin  Cunningham,  M.B.,  Ch.B.,  India, 
W.  T.  Chouhall,  M.D.,  Sydney, 

Alexander  Angus  Martin,  F.R.C.S. Ed.,  North  Shields, 
James  Andrew  Gunn,  M.D.,  Ch.B., 
James  Lawson  Russell,  M.B.,  Ch.B.,  Todmorden. 
Archibald  M'Kendrick,  L.R.C.P.  k  S.Ed.,  Kirkcaldy, 
Alexander  Scott,  M.B.,  CM.,  Broxburn, 
Archibald  Simpson,  M.B.,  Ch.B.,  Darlington, 
Hirjee  Nowon  Anklesaria,  L.R.C.P.  &  S.Ed.,  Bombay, 
Archibald  Cotterell  M 'Master,  M.B.,  Ch.B.      . 
Arthur  James  Lewis,  M.B. ,  Ch.B., 
Herbert  Park  Thompson,  M.D.,  Ch.B., 
Samuel  Davidson,  M.D.,  CM.,  Kelso, 
William  Fowler  Godfrey,  M.B.,  CM., 
H.  St  John  Randell,  M.  B.,  Ch.  B.,  Cape  Colony, 
Kaikhuson  Dadabhoy,  F.R.C.S. Ed.,  L.R. C.P.Ed.,  India, 
William  Joseph  Baird,  M.B.,  Ch.B.,  Earls  Barton,     . 
Edward  Burnet,  M.B.,  Ch.B.,  . 
Arthur  Samuel  Walker,  M.B.,  Ch.B.,  Ashley, 
Archibald  Dunlop  Stewart,  M.  B. ,  L.  R.  C  S.  Ed. , 
Henry  Fleet  Gordon,  M.D.,  L.R.C.P.  &  S.  Ed.,  Winnipeg, 
Edward  Alexander  Elder,  M.B.,  Ch.B., 
Ethelbert  William  Dyer,  M.  B.,  Ch.B. ,  London, 
William  Torrance  Smith,  M.B.,  Ch.B.,  Midcalder,     . 
Arnold  Davies,  M.B.,  Ch.B.,  Menai  Bridge,   . 
Thomas  Graham  Brown,  M.B.,  Ch.B., 


Date  of 

Admission. 

1904 

1904 
1904 
1904 
1904 
1904 
1904 
1904 
1904 
1904 
1904 
1904 
1904 
1904 
1905 
1905 
1905 
1905 
1905 
1905 
1905 
1905 
1905 
1905 
1905 
1905 
1905 
1905 
1905 
1905 
1905 
1905 
1906 
1906 
1906 
1906 
1906 

1906 

1906 
1906 
1906 
1906 
1906 
1906 
1906 
1906 
1906 
1906 
1906 
1906 
1906 
1906 
1906 
1906 
1906 
1906 
1906 
1906 


ALPHABETICAL   LIST   OF   FELLOWS. 


XIX 


John  Bruce  M'Moreland,  M.B.,  Ch.B., 

William  Omand  Sclater,  M.B.,  Ch.B., 

Archibald  George  Kirkwood  Ledger,  M.B.,  Ch.B.,  Darwen, 
465         Frederick  James  Greig,  L.R.C.P.  &  S.I.,  Lt.-Col.,  R.A.M.C. 
Stirling,      ...... 

Duncan  Lorimer,  M.B.,  Ch.B., 

Charles  Robert  Paterson  Mitchell,  Glasgow,     . 

William  David  Osier,     ..... 

John  Halley  Meikle,  M.D.,       .... 
470        David  Lloyd  Roberts,  M.D.,  F.R.C. P.,  Manchester,     . 

James  Sutherland  Edwards,  M.B.,  Ch.B., 

Alexander  Murray  Drennan,      .... 

Mary  Caroline  Hamilton,  L.R.C.P.  &  S.  Ed.,  L.F.P.S.  Glasg 

Elsie  Mary  Macmillan  Barnetson,  M.B.,  Ch.B.,  Joppa, 
475         John  Andrew  Macleod,  M.B.,  Ch.B.,  Inverness 

Hugh  Smith  Reid,  M.D.,  Ch.B., 
477        Allan  Macdonald  Dick,  M.B.,  Ch.B.,  . 


Date  of 

Admission. 
1906 
1906 
1906 

1906 
1906 
1906 
1906 
1906 
1906 
1906 
1907 
1907 
1907 
1907 
1907 
1907 


ORDINARY    FELLOWS. 


ARRANGED    ALPHABETICALLY. 


(a.)   LIFE   MEMBERS. 

Adam,  Dr  George  Roth  well,  84  Collins  St.,  Melbourne,  Aus., 

Anderson,  Dr  John,  Newholme,  Pitlochry, 

Ballantyne.  Dr  Harold  S.,  Ashton,  Eskbank,  Dalkeith, 

Ballantyne,  Dr  J.  W.,  24  Melville  Street, 
5         Barbour,  Dr  A.  H.  Freeland,  4  Charlotte  Square, 

Barclay,  Dr  William  John,  Invercargill,  New  Zealand, 

Brock,  Dr  G.  Sandison,  2  Via  Veneto,  Rome, 

Burnet,  Dr  Edward,  4  Fingal  Place,     . 

Cavanagh,  Dr  Francis,  396  Ecclesall  Road,  Sheffield,  . 
10         Chipman,  Dr  W.  W.,  285  Mountain  St.,  Montreal,  Canada, 

Chouhall,    Dr     William     T.,    233    Macquarie  St.,     Sydney, 
Australia,    ...... 

Craig,  Dr  John,  71  Brunts  field  Place,  . 

Craig,  Dr  William,  71  Bruntsfield  Place, 

Croom,  Dr  David  Halliday,  17  Alva  St., 
15         Croom,  Prof.  Sir  John  Halliday,  25  Charlotte  Square, 

Cumming,  Dr  John,  70  Bruntsfield  Place, 

Dobell,  Dr  C.  B.,  1  Royal  Well  Terrace,  Charlton,  Cheltenham 

Dumat,    Dr   Henry  Aylmer,    7    Devonshire    Place,  Durban 
Natal,  South  Africa,  .... 

Fleming,  Dr  Andrew  M.,  C.M.G.,  Salisbury,  Rhodesia, 
20         Fowler,  Dr  Simson,  Waverley,  Juniper  Green, 

Frost,  Dr  Edmund,  Chesterfield,  Meads,  Eastbourne,  . 

Gibson,  Dr  R.  Wilson,  Town  Head  House,  Orton,  Tebay, 

Grant,  Dr  Lewis,  Neston,  Cheshire, 

Hart,  Dr  D.  Berry,  5  Randolph  Cliff,  . 
25        Inch,  Dr  Robert,  Gorebridge,    .... 

Johnston,  Dr  D.  W.,  P.O.  Box  2022,  Johannesburg,  Trans 
vaal,  ...... 

Livingston,  Dr  George  R.,  47  Castle  Street,  Dumfries, 


1879 
1896 
1897 
1883 
1879 
1899 
1894 
1906 
1903 
1895 

1906 
1900 
1870 
1903 
1870 
1896 
1904 

1898 
1904 
1892 
1905 
1903 
1896 
1877 
1887 

1892 
1898 


XX 


ALPHABETICAL    LIST   OF   FELLOWS. 


30 


55 


40 


45 


M'Arthur,  DrW.  Taylor,  959  S.  Figueroa  St.,  Los  Angeles, 

California ,  . 
M'Brearty,   Dr  J.    Wilson,    Greymouth,    West   Coast,    New 

Zealand,     ....... 

M'Farlane,  Dr  Hilda  M.,  Bendameer,  Burntisland,-    . 

Macnab,  Dr  James,  C.  G.,  The  Towers,  Dysart, 

Maddox,  Dr  Ralph  H.,  I. M.S.,  c/o  Messrs  Thomas  Cook  & 

Son,    Ludgate  Corner,  London,  E.C., 
Martin,   Dr   Christopher,    Cleveland    House,    George  Road, 

Edgbaston,  Birmingham,   .  .  .  .  . 

Melville,  Dr  Kenmure,  2  Nile  Grove,    .  .  . 

Morgan,  Dr  T.  H.,  Gympie,  Queensland,  Australia,     . 
Mules,  Dr  P.  Henry,  Bishopdale,  Nelson,  New  Zealand, 
Pereira,  Dr  A.  A.  Jervis,  Consul  de  Grece    en    Mozambique, 

Lourenco.  Marques,  Delagoa  Bay,  South  Africa,     . 
Pitts,  Dr  Edith  Cochrane-Brown,  Strathmore,  Christ  Church, 

New  Zealand,  ..... 

Ponder,  Dr  Charles  F.,  Glenorchy,  Hobart,  Tasmania, 
Ranking   Dr  J.  E.,  Tunbridge  Wells,  . 
Ross,  Dr  James  F.  W.,  481  Sherbourne  Street,  Toronto,  Canada 
Russell,  Dr  J.  Lawson,  West  Lodge,  Tormorden, 
Simpson,  Dr  G.  F.  Barbour,  50  Melville  Street, 
Simpson,  Dr  W.  Petrie,  Viewbank,  Bathgate, 
Simson,  Dr  H.  J.  F.,  36  Grosvenor  Street,  London,  W., 
Struthers,  Dr  John,  Nqamakwe,  Transkei,  South  Africa, 
Vatve,    Dr   Gopal  Govind,   c/o   H.H.    The   Rajah   of  Miruj 

Bombay,  India,     ..... 
Wells,  Dr  A.  Simpson,  56  Orange  Street,  Cape  Town,  South 

Africa,  ....... 


Date  of 
Admission. 

1901 

1899 
1901 
1904 

1887 

1888 
1900 
1895 
1903 

]888 

1905 
1892 
1881 
1889 
1906 
1898 
1892 
1897 
1895 

1894 

1903 


(6.)    ANNUAL  SUBSCRIBERS. 

Aarons,  Dr  S.  Jervois,  14  Stratford  Place,  London,  W.,  .  1896 

50        Adams,    Dr  Russell  G.   W.,  Langley  Dale,  Blenheim,  New 

Zealand       .......  1904 

Affleck,  Dr  J.  O.,  38  Heriot  Row,  .  .  .  .  1869 

Ainslie,  Dr  A.  C,  49  Minto  Street,       ....  1898 

Aitken,  Dr  C.   J.  Hill,  19  Church  Street,  corner  of  Oxford 

Street,  East  London,  South  Africa.  .  .  .  1902 

Alexander,  Dr  W.  B.,  8  Blenheim  Place,         .  .  .  1882 

55        Allison,  Dr  J.,  Fuller  House,  Kettering,  Northampton,  .  1888 

Anderson,  Dr  Fred.  T.,  20  In verleith  Row,      .  .  .  1892 

Andrew,  Dr  James,  2  Atholl  Crescent, ....  1868 

Anklesaria,  Dr  H.  N.,  12  Colaba  Causeway,  Bombay,  India,  .  1906 

Archibald,  Dr  J.,  Hazelden,  Wimborne  Road,  Bournemouth,  1877 

60         Armitage,  Dr  J.  A.,  58  Waterloo  Road  Wolverhampton,  .  1886 

Armour,  Dr  E.  F.,  6  Bruntsfield  Terrace,  .  .  .  1889 

Aspland,    Dr  W.  H.  Graham,    Church  of  England  Mission, 

Peking,  China,        .  .  .  .  .  .  1901 

Baildon,  Dr  F.  J.,  42  Hoghton  Street,  Southport,       .  .  1887 

Baird,  Dr  W.  J.,  Earls  Barton,  Northants,      .  .  .  1906 

65         Ballantyne,  Dr  A.,  Ashton,  Eskbank,  Dalkeith,  .  .  1870 

Barnardo,    Dr  F.  A.  F.,   Capt.  I. M.S.,  Ferozepore,  Punjab, 

India,  .  .  .  .....  .  1899 

Barnetson,  Dr  Elsie  M„  31  Morton  Street,  Joppa,   '    .  .  1907 


ALPHABETICAL   LIST   OF   FELLOWS. 


XXI 


70 


75 


SO 


85 


90 


95 


100 


105 


1.10 


115 


120 


Barnetson,  Dr  R.  Balfour,  31  Morton  Street,  Portobello, 
Barrington,   Dr     Fourness,  213  Macquarrie  Street,    Sydney, 

Australia,    ...... 

Barry,  Dr  W.  J.  M.,  29  Plymouth  Road,  Penarth,  Glamorgan, 

Bateman,  Dr  F.  J.Harvey,  Heath  End,  Blackheath,  Lond. ,S.E 

Beatty,  Dr  Samuel,  Craigvar,  Pitlochry, 

Beesley,  Dr  R.  W.,  135  Deane  Road,  Bolton,    . 

Beesly,  Dr  Lewis,  13  Torphichen  Street, 

Bell,  Dr  J.  Lumsden,  Driffield,  Yorkshire, 

Bentley,  Dr  G.  H.,  Loanhead  House,  Kirkliston, 

Beveridge,  Dr  Robert,  9  James  Place,  Leith,    . 

Blaikie,  Dr  R.  H.,  10  Mayfield  Gardens, 

Blair,  Dr  J.  A.,  16  Windsor  Terrace,  Newcastle-on-Tyne, 

Blake,  Dr  R.  A.,  Padn oiler,  Sunnyside,  Pretoria,  South  Africa 

Bleloch,  Dr  A.,  26  Gilmore  Place, 

Boddie,  Dr  G.  P.,  73  Brimtsfield  Place, 

Booth,  Dr  William,  2  Minto  Street,      . 

Borrowman,  Dr  Philip  G.,  Galvelmore,  Crieff, 

Boxill,  Dr  N.  L.,  Buttalls,  St  George,  Barbados, 

Brand,  Dr  Eden,  Bellfield,  Banchory,  . 

Brewis,  Dr  N.  T.,  6  Drumsheugh  Gardens, 

Brewis,  Dr  R.  Adams,  The  West  Gate,  Dursley,  Gloucestershire 

Broad,  Dr  B.  W.,  The  Sanitorium,  Cardiff, 

Brodie,  Dr  T.  Scott,  21  Belhaven  Terrace,  Wishaw, 

Brodie,    Dr    W.    Haig,    6   St  Stephen's    Road   West,   West 

Ealing,  London.  W. 
Brown,  Dr  H.  Grey,  1  Cluny  Avenue,  . 
Brown,  Dr  J.  Graham,  3  Chester  Street, 
Brown,  Dr  William,  Braemar,  .... 
Brownlee,    Dr   James,    6    Seaton   Terrace,    Linthrope   Road 

Middlesbrough,       ..... 
Buist,  Dr  J.  W.,  1  Clifton  Terrace,       . 
Buist,  Dr  R.  C,  166  Nethergate,  Dundee, 
Bunting,    Dr    W.    Hartley,    20    Hagley    Road,    Edgbaston 

Birmingham,  ..... 

Burton,  Dr  Thomas  J.,  Port  Hedland,  West  Australia, 
Butchart,  Dr  C.  A.,  52  Leith  Walk,  Leith, 
Cairns,  Dr  W.  Murray,  67  Catherine  Street,  Liverpool, 
Calder,  Dr  H.  L.,  60  Leith  Walk,  Leith, 
Callender,    Dr  D.    A.,    Hazelmere,    Toft  Road,    Knutsford, 

Cheshire,     ..... 
Callender,  Dr  D.  M.,  6  Rose  Bank,  Lancaster, 
Callender,  Dr  T.  M.,  Inverard,  Sidcup, 
Cameron,    Prof.    James    C,    M.D.,    941    Dorchester  Street 

Montreal,    ..... 
Campbell,  Dr  Malcolm,  17  Walker  Street, 
Carmichael,  Dr  Edward,  21  Abercromby  Place, 
Carmichael,  Dr  E.  W.  Scott,  32  Rutland  Square, 
Carmichael,  Pr  James,  22  Northumberland  Street, 
Carrnthers,  Dr  G.  J.  R.,  4  Melville  Street, 
Cattanach,  Dr  J.  G.,  3  Alvanley  Terrace, 
Church,  Dr  H.  M.,  36  George  Square,  . 
Clark,  Dr  A.  W.  G.,  24  Braid  Crescent, 
Clark,  Dr  J.  A.,  4  Cambridge  Street, 
Clark,  Dr  Katherine  S.,  Craigleith  Poorhouse, 
Cobbett,  Dr  C.  N.,  Edmonton,  Alberta,  Canada, 
Cox,  Dr  Joshua  J.,  38  Deansgate,  Manchester, 
Craig,  Dr  R.  W.,  Pathhead-Ford,  Dalkeith,     . 
Oroudace,  Dr  J.  H.,  Foregate  House,  Stafford, 


Date  of 

Admission. 

1904 

1884 
1898 
1898 
1888 
1894 
1904 
1884 
1877 
1896 
1888 
1887 
1905 
1876 
1889 
1891 
1893 
1888 
1903 
1883 
1888 
1895 
1900 

1881 
1905 
1906 
1904 

1905 

1877 
1895 

1900 
1896 
1894 
1892 
1882 

1901 
1902 
1896 

1888 
1900 
1887 
1899 
1871 
1901 
1893 
1875 
1901 
1887 
1903 
1890 
1876 
1905 
1878 


XX11 


ALPHABETICAL  LIST   OF  FELLOWS. 


125 


130 


135 


140 


145 


150 


155 


160 


165 


170 


Cullen,  DrG.  M.,  50  Minto  Street,      . 

Cunningham,   Dr   Barbara   M.,  Dufferin   Hospital,  Nagpur 

Central  Provinces,  India,  . 
Currie,  Dr  A.  S.,  20  Oxford  Terrace,  Hyde  Park,  London,  W. 
Dadabhoy,  Dr  K.,  Karachi,  India, 
Darling,  Dr  T.  Brown,  1 3  Merchiston  Place,    . 
Darling,  Dr  William,  2  Warrender  Park  Terrace, 
Davidson,  Dr  D.  G.,  9  Granville  Terrace, 
Davidson,  Dr  H.  S.,  4  Dundas  Street,  . 
Davidson,  Dr  Samuel,  Kelso,    .... 
Davies,  Dr  Arnold,  Grammar  School,  Menai  Bridge,  North 

Wales,        ...... 

Davies,  Dr  E.  T. ,  1  St  Domingo  Grove,  Liverpool, 

Dendle,  Dr  Frank,  Overton  House,  Spring  Grove,  Isleworth, 

Deverell,  Dr  H.  C,  12  Windsor  Street, 

Dewar,  Dr  M.,  24  Lauriston  Place, 

Dick,  Dr  A.  Iff.,  Edinburgh  University  Union, 

Dickie,  Dr  J.  T.,  37  Lauriston  Place,   . 

Dickson,  Dr  George,  9  India  Street, 

Dickson,  Dr  George,  14  Ardmillan  Terrace, 

Dobie,  Dr  D.  Robertson,  Heathfield,  Crieff, 

Donald,  Dr  C.  W.,  28  Portland  Square,  Carlisle, 

Drennan,  Dr  A.  Murray,  36  Woodburn  Terrace, 

Dunbar,  Dr  H.  J.,  1  Kew  Terrace, 

Duncan,  Dr  A.  J.,  158  Nethergate,  Dundee,    . 

Duncan,  Dr  A.  S.,  ..... 

Dunlop,  Dr  H.  M.,  20  Abercromby  Place, 

Dyer,  Dr  E,  W.,  c/o  Messrs  Webster,  Steel  &  Co.,  5  East 

India  Avenue,  Leadenhall  Street,  London,  E.C.,  . 
Eason,  Dr  John,  58  Northumberland  Street,     . 
Easterbrook,  Dr  A.  M.,  Am  prior,  Gorebridge, 
Easterbrook,  Dr  C.  C,  Glengall,  Ayr,  . 
Easton,  Dr  Thomas,  23  East  Park  Terrace,  Southampton, 
Eden,  Dr  T.  Watts,  26  Queen  Anne  Street,  Cavendish  Squar 

London,  W. ,  .  . 

Edington,  Dr  D.  C,  4  Portland  Place,  Penrith, 
Edwards,  Dr  J.  S.,  University  Union, 
Elder,  Dr  Edward  A.,  6  Torphichen  Street, 
Elder,  Dr  Eleanor,  4  John's  Place,  Leith, 
Elder,  Dr  W.  Nicol,  6  Torphichen  Street, 
Evans,  Dr  O.  F.,  20  Princes  Avenue,  Liverpool, 
Farie,  Dr  G.  J.,  Strathallan  House,  Bridge  of  Allan 
Farquharson,  Dr  J.  D.,  242  Westgate  Road,   Newcastle-on 

Tyne,  ...... 

Faulkner,  Dr  Hugh,  St  John's  House,  Banbury,  Oxon 
Felkin,  Dr  R.  W.,  12  Oxford   Gardens,  North  Kensington 

London,  W.,  .... 

Ferguson,  Dr  J.  Haig,  7  Coates  Crescent, 
Ferguson,  Dr  P.  J.  H. ,  9  Windsor  Street, 
Ferguson,  Dr  R.  T.,  Middlemarch,  Anstruther,  Fife,  . 
Finlay,  Dr  W.  A.,  50  Trinity  Road,     . 
Fitzwilliams,  Dr  D.  C.  L.,  64  Brook  Street,  Grosvenor  Square 

London,  W.,  ..... 

Fleming,  Dr  Andrew,  St  John's  Road,  Corstorphine,  . 
Flett,  Dr  A.  B.,  60  George  Square, 
Forbes,  Dr  J.  Christie,  Ardv*  ich,  Liberton, 
Fordyce,  Dr  A.  Dingwall,  19  Coates  Crescent, 
Fordyce,  Dr  William,  20  Charlotte  Square, 
Fothergill,  Dr  W.  Edward.,  13  St  John  Street,  Manchester, 


Date  of 

Admission. 

1890 

1906 
1882 
1906 
1884 
1900 
1892 
1904 
1906 

1906 
1887 
1892 
1882 
1891 
1907 
1900 
1867 
1901 
1894 
1895 
1907 
1905 
1879 
1890 
1884 

1906 
1899 
1893 
1892 
1894 

1888 
1897 
1906 
1906 
1903 
1879 
1890 
1903 

1890 
1902 

1884 
1885 
1900 
1895 
1880 

1904 
1905 
1903 
1898 
1899 
1888 
1894 


ALPHABETICAL   LIST   OF   FELLOWS. 


XX111 


Forrester,  Dr  C.  C,  3  Albert  Terrace,   . 

Fowler,  Dr  W.  Hope,  5  St  Vincent  Street, 
175         Fox,  Dr  J.  W.,  18  Bernard  Street,  Southampton, 

Fraser,  Dr  J.  Hossack,  Fernfield,  Bridge  of  Allan, 

Fraser,  Dr  Nutting  S.,  205   Gower  Street,  St  John's,  New 
foundland,  ...... 

Frost,  Dr  W.  E.,  6  Atholl  Place, 

Garbutt,  Dr  W.  J.,  1  Bournbrook  Rd.,  Selly  Pk.,  Birmingham 
180         Gardiner,  Dr  Frederick,  9  George  Square, 

Gavin,  Dr  Alfred  T.,  Doonlea,  Dunaskin, 

Gayton,    Dr    William,    Ravensworth,    Regent's    Park    Road 
Finchley,  London,  N., 

Gemmell,  Dr  J.  E.,  28  Rodney  Street,  Liverpool, 

Gibbons,    Dr   Sherwin,    1013  Braly   Building,    Los   Angeles, 
California,  ...... 

185        Gibbs,  Dr  J.  H.,  7  Coates  Place, 

Gibson,  Dr  Cameron  R.,  101  Forest  Road,  Nottingham, 

Giffen,  Dr  J.  T.  M.,  138  Boughton,  Chester,     . 

Giles,  Dr  A.  B.,  4  Palmerston  Place,    . 

Gilmour,  Dr  T.  F.,  Port  Ellen,  Islay,    . 
190        Glegg,  Dr  R.  Ashleigh,  Public  Health  Office,  Leith,    . 

Godfrey,  Dr  W.  F.,  46  Cumberland  Street 

Gordon,  Dr  Henry  F.,  178  Colony  Street,  Winnipeg,  Canada. 

Graham,  Dr  A.,  Curriebank,  Currie, 

Graham,  Dr  D.  J.,  26  Rutland  Street,  . 
195         Graham,  Dr  F.  M.,  16  Mayfield  Gardens, 

Graham,  Dr  J.  Gibson,  17  Ashton  Ter.,  Dowanhill,  Glasgow 

Graham,  Dr  R.  Balfour,  Leven,  Fife,     . 

Green,  Dr  John  Ligertwood,  23  Minto  Street,  . 

Greene,  Dr  T.   W.   N.,  45  Dartmouth  Square,  Leeson  Park 
Dublin,       ....... 

200         Gregory,  Dr  W.  H.,  North  Bar  Street,  Beverley,  Yorks, 

Greig,  Dr  F.  J.,  Lt.-Col.  R.A.M.C.,  16  Melville  Ter.,  Stirling, 

Gunn,  Dr  .  J.  A.,  Materia  Medica  Department,  University  of 
Edinburgh,  .... 

Guthrie,  Dr  A.  Cowan,  21  Pilrig  Street, 

Hall,  Dr  A.  A.,  8  Vanburgh  Place,  Leith, 
205         Hall,  Dr  D.  G.,  30  Brunswick  Place,  Hove,  Brighton 

Hamilton,  Dr  J.  R.,  Elm  House,  Hawick, 

Hamilton,  Dr  Mary,  Pengarth,  St  Agnes,  Cornwall, 

Hamp,  Dr  J.  Walton,  Penn  Road,  Wolverhampton, 

Hardie,  Dr  Mabel,  High  Lane,  near  Stockport, 
210        Harley,  Dr  R.  J.,  .... 

Harlin,    Dr    Francis    W.,    Peak  Downs    District    Hospital 
Clermont,  Queensland,      .... 

Harper,  Dr  R.  A.  J.,  Abbey  Road,  Barrow-in-Furness 

Harvey,   Dr    Charles    E.,    Kingswood,   Sav-la-Mar,  Jamaica 
W.I.,  .... 

Harvey,  Dr  James,  7  Blenheim  Place,  . 
215         Haultain,  Dr  F.  W.  N.,  12  Charlotte  Square, 

Havelock,  Dr  J.  G.,  Sunnyside,  Montrose, 

Hay,  Dr  Henry,  11  Great  King  Street, 

Hellier,  Dr  J.  B.,  Glengariff,  North  Grange  Road,  Headingley 
Leeds,  ..... 

Helm,  Dr  J.  H. ,  Clarence  Cottage,  Ratho, 
220         Helm,  Dr  R.  Dundas,  13  Portland  Square,  Carlisle, 

Helme,  Dr  G.  Edgar,  Gloucester  House,  Rusholme,  Manchester 

Henderson,  Dr  Alexander,  21  Pitt  Street 

Hewetson,  Dr  J.,  Holmfield 


Date  of 
Admission. 
1898 
1900 
1887 
1895 

1887 
1900 
1897 
1900 
1905 

1885 
1885 

1904 
1905 
1903 
1892 
1891 
1882 
J901 
1906 
1906 
1897 
1895 
1894 
1888 
1893 
1902 

1889 
1893 
1906 

1906 
1888 
1905 
1900 
1879 
1907 
1886 
1902 
1905 

1900 
1901 

1889 
1891 
1884 
1888 
1879 

1904 
1888 
1892 
1895 
1891 
1881 


XXIV 


ALPHABETICAL   LIST   OF   FELLOWS. 


Hindmarsh,  Dr  Edwin,  Mozufferpore,  Tirhoot  State  Railway 
Bengal,  India,         ..... 
225         Hobson,  Dr  H.  Overton,  Villa  Sakkara,  Helouan,  Egypt 

Hoggan,  Dr  Robert,  Liberton  Park,  Liberton,  . 

Holmested,  Dr  C.  W.,  Tuxford,  Newark,  Notts, 

Hughes,  Dr  H.  L.,  Llwyn-Werm,  Dowlais,  Glamorganshire, 

Hughes,  Dr  P.  T.,  County  Asylum,  Broomsgrove,  Worcester 
shire,  ....  . 

230        Hunter,  Dr  George,  33  Palmerston  Place, 

Hutcheson,  Dr  J. ,  44  Moray  Place, 

Hutchison,  Dr  Alice  M.,  204  Bruntsfield  Place, 

Inglis,  Dr  Elsie  M.,  8  Walker  Street,    . 

Jamieson,  Dr  Hugh,  1  Strathearn  Road, 
235         Jamieson,  Dr  J.  Boyd,  43  George  Square, 

Jardine,  Dr  Robert,  20  Royal  Crescent,  Glasgow,  W., 

Jeffrey,  Dr  John,  Glen  Bank,  Jedburgh, 

Johnston,  Dr  Robert  B.,  Bishopyards,  Penrith, 

Johnston,  Dr  R.  J.,  1  Buccleuch  Place, 
240         Johnstone,  Dr  R.  W.,  13  Torphichen  Street,    . 

Jones,  Dr  W.  Llewellyn,  58  Thomas  St.,  Merthyr-Tydvil, 

Keay,  Dr  J.  W.,  12  Brougham  Place,    . 

Keiller,  Prof.  Wm.,   210   Levy   Building,  Galveston,  Texas 
U.S.A 

Keir,  Dr  Ian  C,  The  Limes,  Melksham,  Wilts, 
245         Ker,  Dr  Claude  B.,  City  Hospital,  Comiston  Road, 

Kerr,  Dr  J.  M.  Munro,  7  Clairmont  Gardens,  Glasgow, 

Kerr,  Dr  J.  Wishart,  107  Greenhead  Street,  Glasgow, 

King,  Dr  J.  K.,   The    Glen   Springs   Sanitorium,    Watkins 
New  York,  U.S.A.,  ..... 

Kirk,  Dr  Robert,  Rowan  Bank,  Bathgate, 
250        Kirkness,  Dr  J.  M.,  14  Dalkeith  Road, 

Kynoch,  Professor  Campbell,  8  Airlie  Place,  Dundee,  . 

Lackie,  Dr  James,  1  Randolph  Crescent, 

Laing,  Dr  J.  H.  A.,  11  Melville  Street, 

Langwell,  Dr  H.  G.,  4  Hermitage  Place,  Leith, 
255         Leary,  DrT.  Garnet  S.,  Grand  Hotel,  Melbourne,  Australia, 

Ledger,  Dr  A.  G.  K.,  97  Blackburn  Road,  Darwen,     . 

Lee,  Dr  Herbert  E.,  Gunnedah,  N.S.W.,  Australia, 

Lewis,  Dr  Arthur  J.,  c/o  R  Shaw,  Esq.,  36  Woodburn  Terrace 

Littlejohn,  Professor  Harvey,  11  Rutland  Street, 
260         Lochhead,  Dr  James,  Earlston, 

Lockhart,  Dr  F.  A.  L.,  23  Mackay  Street,  Montreal,  Canada, 

Lorimer,  Dr  Duncan,  74  Bruntsfield  Place, 

Low,  Dr  R.  Cranston,  6  Castle  Terrace,  .  . 

Lvell,  Dr  John,  15  Marshall  Place,  Perth, 
265         Lyle,  Dr  F.  W.,  97  Gordon  Road,  Ealing,  London,  W., ' 

Lyle,  Dr  R.  P.  Ranken,  11  Ellison  Place,  Newcastle-on-Tyne 

Mac  Arthur,  Dr  D.  G.,  Aberfeldy, 

M'Call,  Dr  John,  25b  Abercromby  Terrace,  Portobello, 

M'Callum,  Dr  H.,  Kinloch-Rannoch,    . 
270        M'Cann,  Dr  F.  J.,  5  Curzon  Street,  Mayfair,  London,  W.. 

Macdonald,  Dr  Alexander,  42  Polwarth  Terrace, 

Macdonald,  Dr  A.  G.,  11  Manor  Place, 

Macdonald,  Dr  Angus,  27  Manor  Place, 

Macdonald,  Dr  John,  Marathon  House,  Cupar-Fife,     . 
275         Macdonald,  Dr  W.  Fraser,  16  Buckingham  Ter.,  Glasgow,  AY 

M'Ewan,  Dr  Peter,  Royal  Infirmary,  Bradford,  Yorks, 

M'Gibbon,  Dr  John,  22  Heriot  Row,    . 

MacGregor,  Dr  Alastair,  Stafford  Lodge,  Market  Harborough 


Date  of 
Admission. 

1895 
1901 
1894 
1900 
1894 

1895 
1881 
1888 
1905 
1901 
1889 
1900 
1897 
1901 
1903 
1899 
1903 
1903 
1903 

1890 
1903 
1894 
1894 
1901 

1884 
1887 
1903 
1892 
1889 
1891 
1891 
1904 
1906 
1892 
1906 
1890 
1904 
1890 
1906 
1902 
1901 
1890 
1901 
1903 
1886 
1887 
1896 
1898 
1903 
1897 
1902 
1884 
19d5 
1902 
1905 


ALPHABETICAL  LIST   OF   FELLOWS. 


XXV 


280 


285 


290 


295 


300 


SOf 


310 


315 


320 


126 


330 


MacGregor,  Dr  A.  V.,  Durham  House,  West  Hartlepool, 

MacGregor,  Dr  Donald,  Seaton  House,  Jedburgh, 

Macgregor,  Dr  G.  S.,  2  Burnbank  Terrace,  Glasgow  W., 

M'llwraith,  Dr  Kennedy  C,  54  Avenue  Rd.,  Toronto,  Canada 

Mackay,  Dr  George,  74  Bruntsfield  Place, 

Mackay,  Dr  W.  B.,  23  Castlegate,  Berwick-on-Tweed, 

M'Kendrick,  Dr  Archd.,  120  High  St.,  Kirkcaldy, 

Mackenzie,  Dr  R.,  Napier,  Nairn, 

Mackenzie,  Dr  T.  C,  Aberdeen  Royal  Asylum, 

M'Kerron,  Dr  R.  Gordon,  1  Albyn  Place,  Aberdeen,    . 

Mackie,  Dr  George,  Boyd's  Lodge,  Malvern,  Worcestershire, 

Mackin,  Dr  Patrick,  12  Ingestre  St.,  Wellington,  New  Zealand, 

Mackness,  Dr  G.  O.  C.,  Fort  Street  House,  Broughty-Ferry 

Maclagan,  Dr  D.  W.,  Kaponga,  Taranaki,  New  Zealand, 

M'Larty,  Dr  Malcolm,  7  Bellevue  Place, 

M'Lean,  Dr  Archibald,  Crosshouse,  Kilmarnock, 

Maclean,  Dr  Ewen,  J.,  12  Park  Place,  Cardiff, 

Macleod,  Dr  J.  A.,  The  Asylum,  Inverness, 

M 'Master,  Dr  A.  C,  Australasian  Club,  Melbourne  Place, 

Macmillan,  Dr  John,  48  George  Square, 

M'Morland,  Dr  J.  B.,  19  Merchiston  Gardens, 

MacRae,  Dr  John,  Lynwood,  Murray  field, 

Mac  Vie,  Dr  S. ,  Chirnside,  .... 

M'Watt,  Dr  John,  Duns,  .... 

Macwatt,  Dr  R.  C,  7th   Bengal   Cavalry,   c/o  Messrs  King, 

King  &  Co.,  Bombay,  India, 
Malcolmson,  Dr  Alexander  M.,    Dalveen,    St  John's   Road 

Corstorphine,  ..... 

Maloney,  Dr  W.  J.,  Kasr-El.  Aing.  Hospital,  Cairo,    . 
Manford,   Dr   J.    Stanley,  1  Osborne   Terrace,  Newcastle-on 

Tyne,  ....... 

Marshall,  Dr  G.  Balfour,  19  Sandyford  Place,  Glasgow, 
Marshall,  Dr  William,  Milnathort, 

Martin,  Dr  Angus,  25  Northumberland  Square,  North  Shields 
Martin,  Dr  Charles,  Dagenham  House,  Newton  Abbot,  South 

Devon,         ...... 

Martin,  Dr  J.  W.,  Charterhall,  Newbridge,  Dumfries, 

Matheson,  Dr  A.  A.,  41  George  Square, 

Matheson,  Dr  Roderick  M.,  33  Buccleuch  Place, 

Mathewson,  Dr  G.  P.,  25  Cluny  Gardens, 

Maurange,  Dr  Gabriel,  6  Rue  de  Tournon,  Paris, 

Meikle,  Dr  J.  Hally,  12  Midmar  Gardens, 

Menzies,  Dr  David,  20  Rutland  Square, 

Messer,  Dr  Fordyce,  Woodlands,  Garelochhead, 

Michael,  DrGustave,  5  Cambridge  Place,  Chestergate,  Regent 

Park,  London,  N.W., 
Millard,  Dr  W.  W.,  Middlefield  House,  Leith  Walk,    . 
Miller,  Dr  Alexander,  1  Royal  Terrace,  Crossbill,  Glasgow, 
Miller,  Dr  W.  H.,  51  Northumberland  Street,  . 
Milne,  Dr  W.  M.,  10  Newington  Road, 
Mitchell,  Dr  C.  R.  P.,  1  Bowmont  Gardens,  Glasgow, 
Mitchell,  Dr  G.  B.,  1  Skinner  Street,  Whitby, 
Mitchell,    Dr     R.    M.,    Government    Hospital,    Coolgardie 

Western  Australia,  ..... 

Montgomery,    Dr    John,    The    Highlands,     Balsall    Heath 

Birmingham,  ..... 

Moorhouse,  Dr  J.  Ernest,  6  Melville  Terrace  Stirling, 
More,  Dr  James,  Rothwell,  Kettering,  Northampton,  . 
Morison,  Dr  Albert  E.,  Wellington  Road,  West  Hartlepool, 


Date  of 
Admission. 
1895 
1900 
1888 
1901 
1879 
1899 
1906 
1887 
1900 
1896 
1900 
1895 
1887 
1901 
1900 
1890 
1902 
1907 
1906 
1897 
1906 
1893 
1881 
1879 

1885 

1901 
1905 

1900 
1891 
1884 
1906 

1892 
1887 
1887 
1897 
1905 
1898 
1906 
1877 
1866 

1885 
1884 
1902 
1886 
1898 
1906 
1893 

1900 

1895 
1892 
1880 

1888 


62 


XXVI 


ALPHABETICAL   LIST   OF   FELLOWS. 


Morris,  Dr  S.  Glanville,  Brynawel,  Mardy,  Glamorganshire 

Moses,  Dr  0.  St  John,  8  Lansdovvne  Road,  Calcutta,    . 

Mowat,  Dr  John,  5  Hope  Park  Terrace, 

Munro,  Dr  J.  Ramsay,  Sutter  ton,  Boston, 
335         Murray,  Dr  A.  Lang,  Killara,  Sydney,  N.S.W.,  Australia, 

Murray,  Dr  D.  R.,  41  Albany  Street,  Leith, 

Murray,  Dr  James,  1  Brandon  Street,  . 

Napier,   Dr  A.  D.  Leith,    28   Angas  Street,  Adelaide,  South 
Australia,    ...... 

Nicholson,  Dr  H.  Oliphant,  20  Manor  Place,    . 
340         Ogdcn,  Dr  0    Watson,  38  Jesmond  Road,  Newcastle-on-Tyne 

Ogilvy,  Dr  Stewart  Grant,  Fairmont,  Fauldhouse, 

Oliphant,  Dr  E.  H.  Lawrence,  23  Newton  Place,  Glasgow, 

Orr,  Dr  John,  Heather  Lea,  Clarendon  Road,  Eccles,  Lanes., 

Orr,  Dr  W.  Basil,  13  Braid  Road, 
345         Osier,  Dr  W.  D.,  11  Montgomery  Street, 

Paterson,  Dr  G.  Keppie,  19  Albany  Street, 

Paterson,  Dr  G.  W.  Simla,  147  Kruntsfield  Place, 

Patton,  Dr  W.  Scott,  Capt.,  I. M.S.,  "  Scotts  Burn,"  Landour 
Mussoorie,  N.W.P.,  India, 

Pearson,  Dr  C.  M.,  14  Manor  Place,     . 
350         Peddie,  Dr  H.  Anderson,  24  Palmerston  Place, 

Perigal,  Dr  A.,  New  Barnet,  Herts, 

Pirie,  Dr  John,  15  Ardmillan  Terrace, 

Playfair,  Dr  John,  5  Melville  Crescent, 

Poole,    Dr    T.    D.,    North    Side    House,    Linthwaite,   near 
Huddersfield,  ..... 

355         Porritt,  Dr  E.  E.,  Wanganui,  New  Zealand,     . 

Porteous,   Dr  J.    Lindsay,   83  Warburton   Avenue,   Yonkei 
New  York,  ...... 

Porter,  Dr  Frederick,  65  Morningside  Road, 

Potts,  Dr  W.  A.,  118  Hagley  Road,  Edgbaston,  Birmingham, 

Prentice,    Dr    W.     H.,    Brunswick  -  Terrace,    Brood  Street, 
Pendleton,  Manchester,      . 
360         Price,  Dr  A.  W.  Gordon,  9  Grange  Road, 

Price,  Dr  E.  F.  T..  1  Middleby  Street, 

Primrose,  Dr  Alex.,  100  College  Street,  Toronto,  Canada, 

Pringle,  Dr  J.  Hogarth,  172  Bath  Street,  Glasgow,       . 

Proudfoot,  Dr  Thomas,  30  Lauriston  Place, 
365         Rabagliati,  Dr  A.  H.,  1  St  Paul's  Road,  Bradford,  Yorkshire, 

Randell,  Dr  H.  St  John,  Aliwal  North,  Cape  Colony, 

Reid,  Dr  H.  S.,  5  Ravelston  Park,        .  . 

Reid,  Dr  W.  L.,  7  Royal  Crescent  W.,  Glasgow, 

Rendell,    Dr   Herbert  R.,    P.O.   Box   606,   St  John's,   New- 
foundland, .  .  .  .  .  .         •    . 

370        Rhodes,  Dr  J.  H.,  Vicarage  Terrace,  Kendal,  . 

Ritchie,  Dr  James,  22  Charlotte  Square, 

Ritchie,  Dr  W.  T.,  9  Atholl  Place,        .  .  .  . 

Robarts,  Dr  Henry  H.,  Wemyss  Place,  Haddington,   . 

Roberton,  Dr   Ernest,   Cotele  House,  Symond  Street,  Auck- 
land, New  Zealand,  . 
375         Roberts,  Dr  D.  Lloyd,  11  St  John  Street,  Manchester, 

Roberts,  Dr  Ernest  T.,  Oaklands  House,  Keighley, 

Roberts,  Dr  R.  W. ,  Grove  Place,  Port  Talbot,  Glamorganshire, 

Robertson,  Dr  George,  Braehrad,  Viewfield  Place,  Dunfermline, 

Robertson,  Dr  Robert,  26  Royal  Circus, 
380        Robertson,    Dr  W.  B.,  St  Anne's,   101  Thurlow  Park  Road, 
West  Dulwich,  London,  S.E.,         .  .  .  . 

Robertson,  Dr  W.  G.  Aitchison,  26  Minto  Street, 


Date  of 
Admission. 
1894 
1900 
1884 
1901 
1889 
1878 
1879 

1878 
1900 
1900 
1895 
1885 
1887 
1889 
1906 
1882 
1896 

1901 
1902 
1882 
1887 
1888 
1873 

1890 

1897 

1875 
1904 
1897 

1901 
1890 
1890 
1887 
1886 
1884 
1903 
1906 
1907 
1880 

1882 
1898 
1880 
1899 
1904 

1887 
1906 
1890 
1894 
1901 
1897 

1870 

1889 


ALPHABETICAL  LIST   OF  FELLOWS. 


XXV11 


385 


390 


395 


400 


405 


410 


415 


420 


425 


430 


Robins,  Dr  H.,  Sav-la-Mar,  Jamaica,  W.I., 

Robinson,  Dr  H.  Shapter,  Talfourd  House,  78  Peckham  Road 

Camberwell,  London,  S.E., 
Ronaldson,  Dr  T.  R.,  8  Charlotte  Square, 
Rosa,  Dr  Albert  F.,  28  Pitt  Street, 
Ross,  Dr  J.  W.  E.,    1  Clare  Street,  Cardiff, 
Russell,  Dr  W.,  3  Walker  Street, 
Saleeby,   Dr  C.  W.,   13  Greville  Place,  London,  N.W. 
Sandstein,  Dr  Alfred  C,  23  Latimer  Square,  Christchureh 

New  Zealand,         . 
Saunders,    Dr  F.    A.,    Grahamstown,    Cape    Colony,    South 

Africa,         ...... 

Schofield,  Dr  Linn  J.,  Warrensburg,  Mo.,  U.S.A., 
Sclater,  Dr  W.  O.,  16  War  render  Park  Crescent, 
Scott,  Dr  Alexander,  The  Firs,  Broxburn, 
Scott,  Dr  T.  R.,  Musselburgh,   .... 

Secord,  Dr  E.  R.,  112  Market  St.,  Brantford,  Ontario,  Canada 

Shaw,  Dr  C.  J.,  Royal  Lunatic  Asylum,  Montrose, 

Shaw,  Dr  W.  J.,  Cockburnspath, 

Shearer,  Dr  Alfred,  Newtown,  N.  Wales, 

Simpson,  Dr  Archibald,  The  Hospital,  Darlington, 

Simpson,  Dr  F.  D.,  7  Kew  Terrace, 

Slight,  Dr  J.  D.,  61  London  Road,  Leicester, 

Sloan,  Dr  Allen  T.,  22  Ahercromby  Place, 

Sloan,  Dr  S.,  5  Somerset  PI.,  Sauchiehall  St.  West,  Glasgow, 

Sloss,    Dr  William,    Windsor,    Sturt   Street,    Ballarat,    Mel 

bourne,  Australia,  .... 

Smart,  Dr  David,  74  Hartington  Rd.,  Sefton  Park,  Liverpool, 
Smith,  Dr  G.  H.  Walton,  Pendower,  Oxford  St.,  Paddington, 

Sydney*  Australia,  ...... 

Smith,  Dr  Gains  T.,  15  Church  Street,  Moncton,  New  Brunswick, 

.Canada,      ...... 

Smith,  Dr  James,  4  Brunton  Place, 

Smith,  Dr  John,  Hrycehall,  Kirkcaldy, 

Smith,  Dr  W.  Ramsay,  Winchester  St.,  East  Adelaide,  Aus 

Smith,  Dr  W.  Torrance,  Linwood,  Midcalder, 

Sneddon,  Dr  William,  58  Bonnygate,  Cupar-Fife, 

Somerville,  Dr  C.  W.,  London  Mission,  Wuchang,  by  Hankow 

Central  China,         ..... 
Somerville,  Dr  James  W.,  12  Abbotsford  Road,  Galashiels, 
Spalding,  Dr  William,  Gorebridge, 
Spence,  Dr  R.,  St  Ninians,  Burntisland, 
Spence,  Dr  William.  Sydney  House,  Dollar, 
Stephen,  Dr  W.  A.,  Loftus-in-Cleveland,  Yorkshire,    . 
Stevens,  Dr  John,  78  Polwarth  Terrace, 
Stewart,  Dr  A.  D.,  8  Brougham  Place, 
Stewart,  Dr  J.  S..  15  Merchiston  Place, 
Stewart,  Dr  R.,  25  George  Square, 
Stirling,  Dr  R,,  4  Atholl  Place,  Perth, 
Story,  Dr  B.  S. ,  Wellington,  New  Zealand,     . 
Strain,  Dr  Arthur  C. ,  Grange  House,  West  Hartlepool, 
Stumbles,  Dr  H.  M.,  Amble  House,  Amble,  Northumberland 
Sturrock,  Dr  J.  F.,  Arima,  Bronghty-Ferry,     . 
Sullivan,  Dr  John,  34  Gilmore  Place,   . 
Taylor,  Dr  David  R.,  St  Helen's,  Ayton, 
Taylor,  Dr  William,  12  Melville  Street, 
Taylor,  Dr  W.  Macrae,  12  Melville  Street, 
Teacher,  Dr  C,  Ciaieend,  North  Berwick, 
Temple,  Dr  G.  H.,  Ailanthus,  Weston-super-Mare, 


Date  of 

Admission. 

1893 

1890 
1877 
1893 
1904 
1890 
1902 

1898 

1885 
1893 
1906 
1906 
1880 
1902 
1903 
1892 
1898 
1906 
1900 
1898 
1893 
1887 

1902 

1882 

1892 

1891 
1891 
1885 
1892 
1906 
1888 

1902 
1902 
1867 
1878 
1884 
1894 
1894 
1906 
1884 
1885 
1892 
1898 
1904 
1903 
1887 
1902 
1896 
1868 
1895 
1887 
1888 


XXVlll 


ALPHABETICAL  LIST  OF  FELLOWS. 


435 


440 


445 


450 


455 


460 


465 


470 


475 


477 


Tennant,  Dr  John,  Scunthorpe,  near  Doncaster, 
Thatcher,  Dr  C.  H.,  8  Melville  Crescent, 
Thin,  Dr  Robert,  25  Abercromby  Place, 
Thomas,  Dr  G.  Crewdson,  34  West  Hill,  Sydenham,  London 
S.E.,  ...... 

Thompson,  Dr  F.  E.,  20  Park  Avenue,  Montreal,  Canada, 
Thompson,  Dr  Herbert  P.,  c/o  Mackay,  52  Morningside  Road 
Thompson,  Dr  James  L.,  Castlemaine,  Victoria,  Australia, 
Thompson,    Dr  John  A.   Douglas,  Comberton  House,   Hale- 
sowen, Worcestershire,        .... 

Thomson,  Dr  A.  D.  R.,  19  Bridge  Street,  Musselburgh, 
Thomson,  Dr  John,  14  Coates  Crescent, 
Thomson,  Dr  J.  Stitt,  Castle  Hill  House,  Lincoln, 
Thomson,  Lr  T.  J.,  31  Morningside  Road, 
Thyne,  Dr  T.  J.,  16  Randolph  Crescent, 
Tod,  Dr  John,  69  Ferry  Road,  Leith,    . 

Tough,  Dr  F.  W.  K.,  24  Junction  Lane,  St  Helen's  Junction 
Lancashire,  ..... 

Tristan,  Dr  R.  J. ,  28  Carolgate  Retford,  Notts, 
Underhill,  Dr  C.  E.,  8  Coates  Crescent, 

Underhill,  Dr  T.  Edgar,  Dunedin,  Barnt  Green,  Worcestershire 

Vassie,  Dr  Alexander  H.,  98  Priory  Road,  West  Hampstead. 

London,  N.W.,       . 

Vickery,  Dr  W.  H.,  1  Trewartha  Park,  Weston-super-Mare, 

Wade,  Dr  George,  St  John's,  Melrose,  . 

Walker,  Dr  Arthur  S.,  Ashleigh,  Middlesborough, 

Wallace,  Dr  Abraham,  39  Harley  Street,  London,  W. , 
Wallace,  Dr  R.  W.  L. ,  The  Royal  Boscombe  and  West  Hants 
Hospital,  Bournemouth,     .... 

Watson,  Dr  B.  P.,  6  Castle  Terrace,      . 

Watson,  Dr  R.  H. ,  Rousden,  Park  Road,  Hamilton,  . 

Waugh,  Dr  John,  36  Finsbury  Pavement,  London,  E.  C. , 

Webster,  Dr  A.  D.,  18  Minto  Street,   . 

Webster,  Prof.  J.  C,  706  Reliance  Building,  100  State  Street 
Chicago,  U.S.A., 

White,  Dr  A.    L.,   Tantallon,  Manchester  Road,  Castleton 
Manchester,  ..... 

Wilcockson,  Dr  G.  Morton,  Whitley  Cross,  Reading,  . 

Wilkie,  Dr  James,  Selville  House,  Portobello,  . 

Wilkinson,  Dr  George,  3  Dingle  Hill,  Liverpool,  S.,  . 

Will,  Dr  J.  C.  Ogilvie,  17  Bon-Accord  Square,  Aberdeen, 

Williams,     Dr    J.    T.,    Bronygar,     Treharris,    Glamorgan 
shire,  ...... 

Willcox,  Dr  F.  Mayes,  8  Strathearn  Road, 

Wilson,  Dr  James,  53  Inverleith  Row,  . 

Wise,  Dr  Robert,  290  Ivy  dale  Road,  Nunhead,  London,  S.E. 

Wood,  Dr  Thomas,  182  Ferry  Road,     . 

Woodside,  Dr  J.  T. ,  Stewartstown,  Co.  Tyrone, 

Wright,  DrW.F.,         .  ,  . 

Yoe,  Dr  Richard  T.,  2103  Floyd  Street,  Louisville,  Kentucky 
U.S.  A 

Young,  Dr  H.  C.  Taylor,  209  Macquarrie  Street,  Sydney,  New 
South  Wales,  ..... 

Young,  Dr  Peter  A.,  25  Manor  Place,  . 


Date  of 

Admission. 

1902 

1877 

1891 

1899 
1902 
1906 
1894 

1902 
1877 
1887 
1877 
1902 
1887 
1892 

1901 

1887 
1872 
1879 

1891 
1892 
1893 
1906 
1879 

1905 
1902 
1896 
1881 
1881 

1889 

1903 
1893 
1897 
1889 
1867 

1904 
1902 
1889 
1890 
1886 
1898 
1887 

1891 

1900 
1871 


CONTENTS 


I.— COMMUNICATIONS  RELATING  TO  OBSTETRICS. 


PAGE 


Inaugural   Address    on    the    Future    of    Obstetrics.      By  J.  W. 

Ballantyne,  M.D.,  F.R.C.P.E.,  F.K.S.E.  ...         3 

The  Management  of  Some  Difficult  Occipito-Posterior  Cases.    By 

J.  Lamond  Lackie,  M.D.,  F.R.C.P.(Ed.)  ...        28 

On  the  Prognosis  of  Pregnancy  in  Patients  with  one  Kidney,  with 
Notes  of  an  Unusually  Complicated  Case  of  Labour  after 
Nephrectomy.  By  James  Haig  Ferguson,  M.D.,  F.R.C.P.E., 
F.R.C.S.E.,  F.R.S.E .        57 

Successful    Treatment    of    Puerperal   Fever   by   Antistreptococcic 

Serum.    By  Dr  Garnet  Leary  .....        67 

Exophthalmic  Goitre  in  its  Relation  to  Obstetrics  and  Gynaecology. 
By  Professor  Sir  Halliday  Croom,  M.D.,  F.R.C.P.E., 
F.R.C.S.E 143 

Epilepsy  and  the  Status  Epilepticus  in  connection  with  Pregnancy 
and  Labour,  with  Illustrative  Cases.  By  Professor  Robert 
Jardine,  M.D.  (Ed.),  F.F.P.S.  (Glas.)     .  .  .  .165 

A  Series  of  Five  Cases  of  Cesarean  Section  for  Contracted  Pelvis. 
By  Professor  John  A.  C.  Kynoch,  M.B.,  F.R.C.P., 
F.R.C.S.  (Ed.) 221 


II.— COMMUNICATIONS  RELATING  TO  GYNECOLOGY. 

Two  Cases  of  Pregnancy  complicated  by  Fibroid  Tumours,  treated 
by  Hysterectomy.  By  N.  T.  Brewis,  M.B.,  F.R.C.P.E., 
F.R.C.S.E 49 


XXX  CONTENTS. 

PAGE 

Case  of  Acute  Albuminuria,  caused  by  the  Pressure  of  a  Tumour  on 
both  Ureters — Operation — Recovery.  By  Frederick  Porter, 
M.B.,  CM. 75 

Intractable  Uterine  Haemorrhage,  and  Arterio- Sclerosis  of  the 
Uterine  Vessels.  By  Elizabeth  H.  B.  Macdonald,  M.A., 
M.D.,  Ch.B 83 

A  Clinical  and  Anatomical  Study  of  Thirty  Cervical  Fibroids 
removed  by  Abdominal  Hysterectomy.  By  F.  W.  N. 
Haultain,  M.D.,  F.R.C.P.  (Ed.) 121 

Hysterectomy  for  Fibroid  Tumours  in    Pregnancy.      Two  Cases. 

By  A.  H.  F.  Barbour,  M.D.,  F.R.C.P.E.  .  .  .136 

Bilateral  Ovarian  Dermoid  Tumours,  complicating  Pregnancy.    By 

Malcolm  Campbell,  M.A.,  M.B.,  B.Ch.,  F.R.C.S.E.    .  .184 

Six  Cases  of  Vaginal  Cesarean  Section.    By  N.  T.  Brewis,  M.B., 

F.R.C.P.E.,  F.R.C.S.E 191 


III.— MISCELLANEOUS  COMMUNICATIONS. 

A  Case  of  Repeated  Abortion  due  to  Syphilis  ;  Treatment  by 
Potassium  Iodide.  Birth  of  Child  with  Congenital  Goitre. 
By  B.  P.  Watson,  M.D.,  F.R.C.S.E 204 

The  "  Byrth  of  Mankynde."    (Its  Contents.)    By  J.  W.  Ballantyne, 

M.D.,  F.R.C.P.(Edin.),  F.R.S.  (Edin.)     .  .  .  .236 


TABLE    SHOWING    SPECIMENS     EXHIBITED 
AT  MEETINGS. 

I.—OBSTETRICAL  AND  TERATOLOGICAL. 

PAGE 

Foetus  (extra-uterine),  four  months',  removed  by  vaginal  section  ; 

and  a  portion  of  the  placenta  (Dr  Brewis)  .  .  .  140 

Foetus,  frozen  sections  of,  showing  hidden  cervical  spina  bifida  (Dr 

J.  W.  Ballantyne)  .  .  .  .  .  .  .121 

Kidneys,  pair  of  cystic  (adenomatous),  from  a  still-born  foetus 

(Dr  J.  W.  Ballantyne)       .  .  .  .  .  .120 

Ovum,  specimen  of  an  early  (Dr  James  Ritchie)       .  .  .  48 

Pelvis  (justo-minor,   with  rickets),  from  primipara  who  died  in 

eclamptic  coma  (Dr  Haig  Ferguson)        .  .  .  .142 

Specimen,  analogous    to    "Foetus    Ovideus,"    obtained    from    a 

multipara  (Dr  Haultain)  ......  48 

II.— GYNECOLOGICAL. 

A.  AFFECTIONS  OF  UTERUS. 
(1)  Fibkoid  Tumours— 
(a)  Simple — 

Fibroid,  soft  subperitoneal,  resembling  ovarian  cyst, 
removed  by  abdominal  hysterectomy  (Dr  Haig 
Ferguson)  ......  47 

Fibroid,  multiple,  giving  rise  to  retention  of  urine  (Dr 

Haultain)  ......  75 

Fibroid,  cervical,  growing  from  anterior  wall  of  cervix  and 

removed  by  pan-hysterectomy  (Dr  Brewis)      .  .  141 

Pelvic  Abdominal  Tumour,  consisting  of — (1)  large  sub- 
mucous fibroid  j  (2)  fibroid  between  the  layers  of  right 
broad  ligament  and  united  with  the  submucous 
fibroid  (Dr  Haig  Ferguson)      .  ,  .  .142 

xxxi 


XXX11  TABLE   OF   SPECIMENS. 

(1)  Fibroid  Tumours — continued, 
(a)  Simple — continued. 

Fibroid,  cervical  (Dr  Fordyce)  .  .  .  .  1 04 


VA.  Jfr. 


Fibroids,  multiple,  removed  for  pressure  symptoms  (Dr 

Fordyce)  .  .  .  .  .  .  |f>4 

Fibroids,  multiple,  removed  for  post-climacteric  haemor- 
rhage (Dr  Fordyce)         .  .  .  .  1 64 

Uterus  containing  a  large  Submucous  Fibroid  attached  by 

broad  pedicle  to  fundus  (Dr  Brewis)    .  .  .  190 

Fibroid,  large  soft  oedematous,  removed  by  hysterectomy 

(Dr  Brewis)         .  .  .  .  .  .190 

Fibroid,  cervical,  weighing  12  lbs.,  causing  retention  of 
urine;  removed  by  supravaginal  hysterectomy 
(Professor  Kynoch)         .....  220 

Mucous    Polypus  and  Adenomatous  Growth  associated 

with  Fibroid  Uterus  (3  specimens),  (Dr  Haultain)     .  75 

Fibroids  complicating  Pregnancy — 

Uterus  with  large  Cervical  Fibroid,  removed  at  the  fifth 
month  of  pregnancy  j  Caesarean  section  and  hyster- 
ectomy (Dr  Brewis)         .  .  .  .  .  44 

Uterus  with  Fibroid  Tumour  in  lower  uterine  segment, 
removed  at  term  by  supravaginal  hysterectomy  after 
Caesarean  section  (colloid  degeneration  of  the 
fibroid),  (Dr  Brewis)       .....  45 

Uterine  Fibroid,  complicated  with  pregnancy  at  fourth 

month,  removed  by  hysterectomy  (Professor  Kynoch)  220 


(b)  Degenerated — 

Fibroid,  large  subperitoneal,  showing  mucoid  degeneration, 

with  a  very  small  pedicle  (Dr  Brewis)  .  .  .  141 

Fibroid,  interstitial,  showing  necrobiosis  (Dr  Fordyce)      .  164 


(c)  With  malignancy — 

Uterus  showing  combined  Fibroid  Tumour  and  Carcinoma 

(Dr  Fordyce)  164 


TABLE  OF   SPECIMENS.  XXxiil 

(2)  Malignant  Disease  of  Uterus — 

PAGE 

Uterus  with  Fundal  Carcinoma,  removed  by  vaginal  hyster- 
ectomy from  multipara  eet.  55  (Dr  Haig  Ferguson)  .  46 

Chorion  Epithelioma  of  Uterus,  removed  by  vaginal  hyster- 
ectomy from  patient  set.  38  (Dr  Haig  Ferguson)     .  .  46 

Sarcomatous  Uterus,  round-celled,  which  filled  entire  cavity, 
perforated  the  wall,  and  involved  the  peritoneal  cavity  j 
abdominal  section  (Dr  Haultain)      ....  74 

Uterus  with  Adeno-carcinoma  of  body,  removed  per  vaginam 

from  multipara  aet.  42  (Dr  Haig  Ferguson)  .  .  163 

Carcinoma  of  Uterus  (3  specimens — 2  cervical,  1  corporeal), 

removed  by  vaginal  hysterectomy  (Dr  Fordyce)     .  .  1 64 

Uterus  with  Adeno-carcinoma  of  the  body,  removed  by  vaginal 

hysterectomy  from  multipara  set.  44  (Dr  Haig  Ferguson)  191 


(3)  Other  Uterine  Conditions— 

Inverted  Uterus  of    puerperal  origin,   removed  by  vaginal 

hysterectomy  (Dr  Haig  Ferguson)   ....  46 

Uterus  (transformed  into  abscess  cavity),  removed  by  vaginal 
hysterectomy  one  year  after  double  pyosalpinx  had  been 
removed  by  abdominal  section  (Dr  Haig  Ferguson)  .  47 

Specimen  of  Diffuse  Uterine  Fibrosis  (Dr  Haultain)    .  .  74 

Uterus  removed  by  abdominal  hysterectomy  for  perforating 
abscess  of  its  wall,  arising  from  septicaemia  after  abortion 
(Dr  Haultain)  ......  74 

Specimen  showing  Tubercular  Endometritis  (Dr  Haultain)     .  164 

Uterus  removed  by  vaginal  hysterectomy  for  bleeding  (and, 
from  same  patient,  a  Haematoma  of  left  broad  ligament) 
(DrBrewis)    .......  190 

B.  AFFECTIONS  OF  THE  OVARIES. 

Fibrous  Tumour  of  Ovary,   which  had  been  wedged  in  pelvis, 

simulating  uterine  tumour  ;  abdominal  section  (Dr  Barbour)  .  121 

Iluptured    Ovarian    Cyst,   with    pseudo-myxoma    peritonei    (Dr 

Barbour)     ........  121 

Ovarian  Tumour  (cyst),  removed  by  abdominal  section  from  a 
patient  who  had  been  operated  on  by  Thomas  Keith  nineteen 
years  before  (Dr  Brewis)  .  .  .  .  .  .  141 


TEANS  ACTIONS 


EDINBURGH  OBSTETRICAL  SOCIETY, 

FOE  SESSION  LXVIIL,  1906-1907. 


Meeting  I.— November  14,  1906. 
Dr  J.  W.  Ballantyne,  President,  in  the  Chair. 

I.  The  Treasurer  {Dr  Wm.  Craig)  made  his  Annual  State- 
ment, which  is  given  below : — 


INCOME. 

Balance  from  Session  1904-1905, 

Arrears,         .         .        .         . 

Bank  Interest  on  Deposit  Receipts,    . 

Interest  on  Consols,     . 

Entrance  Fees  from  28  new  Ordinary- 
Fellows, 

Annual  Contributions  from  380  Ordinary 
Fellows,  

Composition  for  Life-Membership  from 
Four  Ordinary  Fellows,  .... 

Transactions  sold, 


£10 
9 
6 

1 
5 
0 

0 
3 

8 

29 

8 

0 

95 

0 

0 

21 

4 


0     0 

2     0 


£563     6     2 


174  16  11 

£738     3     1 


EXPENDITURE 

Corporation  Duty, 

Income  Tax, 

Shorthand  Reporters, 

Commission  to  Collector, 

Doorkeeper's  Salary,    . 

Oliver  &  Boyd's  Account  for  Vol.  XXXI 

of  Society's  Transactions  (550  copies)^ 
Oliver    &    Boyd's  Account    for  Printing 

Billets,  Postages,  etc., 
Bent  of  Rooms  and  Carriage  of  Books, 
Waterston  &  Sons'  Account, 
The  Secretaries  and  Editor,  for  Postages, 
Blocks  for  Illustrations, 

Balance  to  New  Account,1 


£0  10 

11 

0  6 

6 

11  11 

0 

1  13 

0 

1  16 

0 

102  12 

6 

30  3 

0 

5  2 

0 

11  9 

9 

0  8 

0 

8  2 

6 

£173  15     2 
564     7  11 

£738     3     1 


i  Of  this  Balance,  the  sum  of  £250,  10s.  6d.  is  invested  in  2£  per  cent.  Consols. 

A 


2  ELECTION  OF  OFFICE-BEARERS,   ETC. 

The  accounts  were  audited  by  Dr  Nicholson  and  Dr  Dewar, 
and  found  correct. 

Dr  Freeland  Barbour,  seconded  by  Dr  Lamond  Lackie,  moved 
a  hearty  vote  of  thanks  to  the  Treasurer,  which  was  unanimously 
accorded. 

II.  The  Society  then  proceeded  to  the  election  of  Office- 
bearers for  the  present  Session,  and  the  President  announced 
the  result  as  follows  : — President,  Dr  J.  W.  Ballantyne ;  Vice- 
Presidents  {Senior),  Dr  Berry  Hart ;  {Junior),  Dr  Wm.  Fordyce ; 
Treasurer,  Dr  Wm.  Craig ;  Secretaries,  Dr  Lamond  Lackie  and 
Dr  Barbour  Simpson ;  Librarian,  Dr  Haultain ;  Editor  of  Trans- 
actions, Dr  Angus  Macdonald;  Members  of  Council,  Dr»K  T. 
Brewis,  Dr  Munro  Kerr,  Dr  Freeland  Barbour,  Dr  Haig 
Ferguson,  Sir  Halliday  Croom,  Dr  Samuel  Sloan  (Glasgow),  Dr 
Macrae  Taylor,  Dr  Scott  Carmichael. 

III.  The  following  gentlemen  were  elected  Ordinary  Fellows 
of  the  Society :— E.  Burnet,  B.A.,  M.B.,  Ch.B.,  4  Fingal  Place, 
Edinburgh;  A.  S.  Walker,  M.B.,  Ch.B.,  Ashleigh,  Middles- 
borough;  Archibald  Dunlop  Stewart,  M.B.,  L.E.C.S.E.,  8 
Brougham  Place,  Edinburgh ;  Henry  F.  Gordon,  M.D.,  L.K.C.P. 
&  S.E.,  178  Colony  Street,  Winnipeg,  Canada;  E.  A.  Elder, 
M.A.,  B.Sc,  M.B.,  Ch.B.,  6  Torphichen  Street,  Edinburgh;  E. 
W.  Dyer,  M.B.,  Ch.B.,  c/o  Messrs  Webster,  Steel  &  Co.,  5  East 
India  Avenue,  London,  E.C. ;  W.  T.  Smith,  M.B.,  Ch.B.,  Linwood, 
Midcalder;  Arnold  Davies,  B.A.,  M.B.,  Ch.B.,  Menai  Bridge, 
North  Wales ;  T.  Graham  Brown,  B.Sc,  M.B.,  Ch.B.,  3  Chester 
Street,  Edinburgh;  John  B.  M'Morland,  M.B.,  Ch.B,  19 
Merchiston  Gardens,  Edinburgh;  W.  0.  Sclater,  B.Sc,  MB., 
Ch.B.,  16  Warrender  Park  Cresent,  Edinburgh;  A.  G.  K. 
Ledger,  M.B.,  Ch.B.,  Tupsley,  Hereford;  F.  T.  Greig,  LE.C.P. 
&  S.E.,  (Lt.-Col.  E.A.M.C.,  retired),  16  Melville  Terrace,  Stirling; 
Duncan  Lorimer,  B.Sc,  M.B.,  Ch.B.,  7  Gillsland  Eoad,  Edinburgh ; 


ADDRESS   ON  THE   FUTURE   OF   OBSTETRICS.  3 

Chas.  Kobert  Mitchell,  M.B.,  Ch.B.,  Koyal  Maternity  Hospital, 
Edinburgh;  W.  D.  Osier,  M.B.,  CM.,  11  Montgomery  Street, 
Edinburgh ;  Dr  J.  Halley  Meikle,  44  Morningside  Drive,  Edinr. 

IV.  INAUGURAL   ADDRESS   ON   THE    FUTURE   OF 
OBSTETRICS. 

By  J.  W.  Ballantyne,  M.D.,  F.R.C.P.,  F.R.S.  Edin.,  Lecturer  on  Mid- 
wifery and  Gynaecology,  Surgeons'  Hall  and  Medical  College  for 
Women,  Edinburgh;  Physician  to  the  Royal  Maternity  and 
Simpson  Memorial  Hospital,  Edinburgh,  etc. 

Ladies  and  Gentlemen,  Fellows  of  the  Edinburgh  Obstetrical 
Society, — "To  inaugurate,"  said  Dr  Johnson,  in  that  famous 
Dictionary  of  his,  means  "  to  begin  with  good  omens,"  or  simply 
"to  begin."  His  worthy  follower  in  the  art  and  science  of 
lexicography,  Dr  James  A.  H.  Murray,  in  that  marvel  of  patient 
research  and  brilliant  scholarship,  the  New  English  Dictionary 
on  Historical  Principles,  after  quoting  Johnson's  early  definition, 
proceeds  to  amplify  and  lead  out  the  meaning  of  the  rich  and 
suggestive  word  inaugurate  in  this  manner :  "  to  begin  (a  course 
of  action,  period  of  time,  etc.,  especially  of  an  important 
character)  with  some  formal  ceremony  or  notable  act;  to  com- 
mence, enter  upon,  to  introduce,  usher  in,  to  initiate."  And 
then  our  fellow-countryman,  with  that  dry  humour  which  breaks 
out  now  and  then  even  in  his  Dictionary,  places  within  brackets 
the  following  additional  definition:  "inaugurate,  sometimes 
merely  grandiose  for  begin."  Now  I  feel  grateful  to  Dr  Murray 
for  so  slyly  slipping  that  bracketed  addendum  into  his  already 
full  page;  for  I  see,  with  relief,  that  I  can  shelter  myself 
behind  it,  and  can  plead  that  if  this  address  fall  short  of  being 
a  worthy,  a  notable,  and  an  auspicious  ceremonial  act  at  the 
commencement  of  this,  the  sixty-eighth  session  of  our  Society's 
history,  it  can  at  least  claim  to  be,  beyond  any  cavilling,  a 
beginning. 


4  ADDRESS   ON  THE  FUTURE  OF  OBSTETRICS, 

A  valedictory  address  naturally  enough  concerns  itself  with 
what  is  past,  and  has  a  ring  of  finality  and  farewell  in  it,  vale  ! 
vale!  sounding  out  from  it  with  pathetic  cadence;  but  an 
inaugural  address  looks  forward  to  the  future  and  dwells  upon 
it,  not  without  hope  and  expectation  of  the  good  and  great 
things  that  are  to  come  out  of  it,  for  at  the  very  heart  of  the 
word  inaugural  lies  the  root  augur,  and  the  augur  had,  of  all 
men,  to  be  always  looking  forward.  The  Eoman  augur  was,  as 
we  remember,  or,  as  Dr  Murray  will  tell  us,  if  we  have  forgotten, 
"  a  religious  official  whose  duty  it  was  to  predict  future  events 
and  advise  upon  the  course  of  public  business,  in  accordance 
with  omens  derived  from  the  flight,  singing,  and  feeding  of  birds, 
the  appearance  of  the  entrails  of  sacrificial  victims,  and  other 
portents."  Now,  although  the  primary  visual  image  thus  con- 
jured up  can  hardly  be  said  to  reside  any  longer  in  the  derivative 
words  inaugural,  augury,  and  august ;  although,  also,  the  augur 
himself,  with  his  staff  and  auspicial  rites,  has  long  since  passed 
into  the  thick  mists  which  cover  even  the  brightest  phenomena 
(and  he  was  not  very  luminous  ever)  of  a  bygone  age,  uttering 
his  vale  !  yet  the  augural  spirit  is  not  dead  in  these  days,  but 
is  as  living  and  insistent  now  as  it  ever  was  during  all  the 
centuries  which  have  elapsed  since  man  first  began  to  ask 
questions  about  himself  and  his  future.  In  vulgar  form  it  is 
seen  in  the  irresponsible  and  sensational  sisterhood  of  the  lady 
palmists,  the  crystal-gazers,  and  the  Sibylline  vendors  of  wonder- 
working remedies  and  charms.  It  assumes  scientific  shape  in 
the  daily  forecasts  of  the  weather  to  be  expected  in  these  islands, 
although  it  must  be  owned  that  the  meteorologist,  being  limited 
to  observations  made  upon  the  surface  of  the  earth,  and  having 
no  stations  high  up  among  the  clouds,  sometimes  fails  as  com- 
pletely in  his  foretelling  as  does  the  itinerant  gipsy.  In  our 
own  profession  we  seek,  in  a  legitimate  and  proper  fashion  of 
course,  to  pierce  the  veil  which  hides  the  future  from  us,  and 
we  have  recourse  to  the  bacteriologist  with  his  opsonic  index 


BY  DR  J.    W.    BALLANTYNE.  5 

and  Widal  test,  to  the  histologist  with  his  methods  of  cyto- 
diagnosis  and  differential  blood-counts,  and  to  the  cryoscopist 
with  his  osmotic  and  ionic  actions. 

There  is,  in  a  sense,  the  would-be  augur  in  us  all;  and, 
having  now  in  hand  the  giving  of  an  inaugural  address,  I 
bethought  me  that  I  also  might  try  to  play  the  augur's  part  and 
endeavour  to  forecast  the  future  of  obstetric  theory  and  practice. 
If  I  fall  far  short  of  what  you  may  expect ;  if  I  fail  to  please 
even  myself  (as  is  indeed  very  likely) ;  if  the  manner  and  form 
of  the  forecasting  be  contrary  to  the  traditions  of  Inaugural 
Addresses  in  learned  societies ;  if,  in  striving  not  to  be  dull,  I 
become  extravagant ;  and  if,  in  seeking  to  restrain  fancy  I  run 
the  risk  of  being  prosaic;  then  let  the  blame  rest  upon  the 
etymologies  which  have  led  me  into  such  difficult  territories, 
and  please  let  it  be  remembered  that  after  all  "inaugurate" 
may  be  only  "grandiose  for  begin." 

In  Touch  with  the  Future. 

I  suppose  that  it  was  one  evening  in  the  autumn  that  the 
events  I  am  going  to  relate  apparently  took  place.  I  had,  I 
fancy,  been  reading  about  some  of  the  marvels  of  modern 
psychology,  had  been  learning  how  a  personality  can  be 
dissociated  (on  paper  at  least),  had  been  grasping,  with  some 
difficulty,  that  the  ego  is  not  one  but  two  or  three,  and  had 
been  trying,  without  entire  success,  to  understand  the  mysteries 
of  the  subliminal  and  the  supraliminal.  Then  I  had  begun  to 
wonder  what  subject  I  should  choose  for  an  inaugural  address 
to  the  Society  which  had  so  highly  honoured  me  by  placing  me 
in  its  Presidential  Chair.  I  was  not  finding  the  question  one 
which  admitted  of  easy  solution.  My  mind,  in  freakish  fashion, 
began  to  hunt  ideas,  starting  a  new  one  every  few  minutes,  and 
chasing  it  until  another  idea  suddenly  emerged  from  the  sub- 
conscious somewhere  of   brainland  and  engaged  its   attention. 


6  ADDRESS   ON  THE  FUTURE  OF  OBSTETRICS, 

The  house  was  very  quiet,  and  my  thoughts  wandered  on, 
undisturbed  by  any  extraneous  interruptions,  save  the  occasional 
fall  of  a  cinder  into  the  fireplace,  or  the  coming  of  a  sort  of 
breathless  bark  from  my  dog,  enjoying  doubtless  the  exciting 
pleasure  of  a  subconscious  chase  after  some  old  enemy.  Suddenly 
the  telephone  gave  one  of  those  undecided,  apocopated,  monosyl- 
labic tinkles  that  we  usually  leave  unanswered,  and  regard  as 
due  to  a  fault  in  the  apparatus  or  an  error  of  the  operator. 
On  this  occasion,  however,  I  put  my  ear  to  the  instrument  and 
whispered  "  Hullo  ! "  To  my  surprise  an  answering  "  Hullo  ! " 
very  faint  and  distant,  but  quite  distinct,  came  back.  "Who 
are  you  ? "  I  asked. 

"  One  nine  four  nought,"  was  the  reply. 

"  Thank  you,"  I  said,  "  but  I  don't  want  to  know  your  number ; 
I  wish  to  know  who  you  are,  and  where  you  are  ringing  up  from." 

"  I  am  not  ringing  up  from  anywhere,"  said  the  voice ;  "  you 
are  on  the  Time  Exchange,  and  until  you  grasp  that  notion 
firmly  you  cannot  understand  who  I  am." 

"  I  beg  your  pardon,"  I  exclaimed  in  great  surprise ;  "  I  have 
heard  of  many  Exchanges,  but  never  of  the  Time  Exchange." 

"  That  I  can  quite  well  believe,"  replied  my  unknown  cor- 
respondent. "It  was  only  on  rare  occasions  that  you  in  the 
beginning  of  the  Twentieth  Century  got  switched  on  to  the 
Time  System  instead  of  the  Place  System ;  you  happen  to  have 
been  attached  to-night,  and  I  thought  I  might  venture  to  ring 
you  up  and  have  a  talk.     So,  now  do  you  know  who  lam?" 

"  I  am  really  very  sorry,"  I  replied,  "  but  I  haven't  an  idea." 

"I  thought  you  might  have  guessed,"  he  said.  I  am  an 
officialof  the  Edinburgh  Obstetrical  Society,  and  the  time  from 
which  I  am  ringing  you  up  is  one  nine  four  nought,  or,  if  you 
prefer  it,  nineteen  hundred  and  forty,  the  Centenary  year  of  the 
Society's  existence.  You  are  not  forgetting,"  he  added,  "that 
our  Society  was  born  in  1840,  having  been  conceived,  so  to  say, 
in  the  last  month  of  1839." 


BY  DR  J.    W.    BALLANTYNE. 


For  the  moment  I  was  too  surprised  to  answer  this  startling 
communication  from  the  future;  but  I  soon  recovered  myself 
and  made  a  suitable  reply  to  the  Centenary  Official's  remark. 


The  Future  of  Obstetrics. 

The  next  question  that  came  to  me  over  the  wires  stimulated 
my  curiosity  and  determined  the  course  of  our  conversation:  it 
was,  "  Now,  is  there  nothing  you  would  like  to  ask  me  about 
obstetrics  in  1940  ? " 

"  If  you  will  let  me  get  my  thoughts  gathered  together,"  I 
replied,  "  there  are  hundreds  of  questions  I  should  like  to  ask 
you." 

"I  do  not  promise  to  answer  them  all,"  replied  Nineteen 
Forty  as  I  may  call  him,  "  for  there  are  some  matters  which  I 
could  not  make  plain  to  you  without  a  great  deal  of  preliminary 
explanation,  and  we  have  not  time  for  that ;  but  I  will  do  what 
I  can  to  satisfy  your  curiosity." 

"  What  sort  of  preliminary  explanation  do  you  mean  ? " 

"Well,  this  simply :  Obstetrics  has  not  been  the  only  subject 
of  study  in  which  there  have  been  advances  and  discoveries ; 
there  have  been  great  changes  in  surgery,  still  greater  ones  in 
medicine,  and  a  revolution  in  physics  and  physiological  and 
pathological  chemistry ;  it  would  require  a  series  of  lectures  to 
bring  your  general  knowledge  of  these  matters  up  to  the  level 
required  for  the  perfect  understanding  of  all  that  has  been 
accomplished  in  obstetrics." 

"  I  fully  grasp  the  situation,"  was  my  reply.  "  I  am  now  in 
a  position  similar  to  that  in  which  an  old  friend  of  mine  found 
himself  in  1906 :  he  had  been  in  Central  Africa  for  fifteen  or 
twenty  years,  and  he  came  back  to  his  native  land  to  find  the 
pathologists  speaking  the  (to  him  unknown)  language  of  bac- 
teriology. He  had  the  greatest  difficulty  in  making  up  leeway, 
and  indeed  never  quite  succeeded  in  doing  so." 


8  ADDRESS   ON  THE  FUTURE  OF  OBSTETRICS, 

"You  are  really  in  a  worse  state  than  he  was,"  said  Nine- 
teen Forty,  "  but  I  shall  try  to  make  things  as  simple  as  I  can." 

Teaching  of  Obstetrics. 

"  Being  a  teacher,"  I  now  said,  "  I  should  like  to  hear  about 
your  methods  of  conveying  obstetric  information  in  the  year 
1940." 

"Ah,"  said  my  correspondent,  "you  were,  as  perhaps  you 
suspected,  on  the  eve  of  great  changes  in  your  teaching  methods 
in  the  year  1906.  You  were  under  the  intolerable  burden  of 
having  to  give  fifty  or  one  hundred  hours  of  purely  theoretical 
teaching  in  order  to  fulfil  the  requirements  of  the  examining 
boards.  You  delivered,  each  day,  a  lecture  of  an  hour's  length, 
containing  usually  a  bald  statement  of  a  number  of  facts  dis- 
coverable in  almost  any  reputable  text-book  upon  the  subject ; 
you  occasionally  tried  to  relieve  the  weariness  and  monotony  of 
your  exposition  by  a  passing  reference  to  a  specimen  or  a 
diagram,  or  by  the  introduction  of  an  anecdote  or  a  personal 
experience ;  you  adopted  a  didactic  or  a  grandiloquent  style,  or, 
worse  still,  you  read  slowly  and  closely  from  a  bulky  bundle  of 
manuscript  notes.  You  occasionally  put  forceps  on  to  the  doll 
in  the  phantom,  but  you  lectured  all  the  time,  and  you  expected 
your  students  to  be  taking  down  your  words  in  their  note-books, 
when  you  were  directing  their  attention  to  the  movements  of 
your  hands  in  the  act  of  inserting  the  blades  of  the  instrument. 
All  this  was  altered  at  once  when  in  the  University  and  College 
Eegulations  the  words  'hour's  instruction'  took  the  place  of 
'  lecture ' ;  instead  of  having  to  give  fifty  or  a  hundred  lectures, 
you  were  asked  to  supply  fifty  or  a  hundred  hours  of  obstetric 
instruction,  a  very  different  thing,  as  you  can  imagine.  Of 
course  some  lecturers  preferred  to  go  on  in  the  old  way,  and 
they  were  at  liberty  to  do  so;  but  many  chose  to  vary  the 
methods  which  had  been  in  vogue.     Here,  for  instance,  is  a  plan 


BY  DR  J.   W.    BALLANTYNE.  9 

which  was  adopted  not  so  long  after  the  time  at  which  you  now 
are.  Each  student  was  supplied  with  a  neatly  printed  and 
fairly  full  statement  of  the  subject  of  demonstration  to  be 
taken  up  on  the  following  day ;  to  this  were  attached  two  or 
three  blank  sheets  for  the  noting  down  of  additional  facts,  for 
the  drawing  of  a  few  diagrams,  or  for  the  indication  of  the  page 
or  pages  in  a  large  text-book  where  full  details  might  be  found. 
Having  perused  this  syllabus  or  epitome  the  night  before,  the 
student  came  prepared  to  follow  and  appreciate  the  teaching  his 
teacher  was  ready  to  give  him.  It  might  take  the  form  of  a 
demonstration  of  pelvimetry  in  normal  and  malformed  pelvises. 
On  a  number  of  tables  were  several  models  of  the  well-formed 
and  the  deformed  pelvis,  with  callipers  of  various  kinds  lying 
beside  them.  The  teacher  at  first  gave  a  very  concise  and  clear 
statement  of  the  measurements  of  the  diameters  in  the  normal 
and  in  the  abnormal  pelvis,  and  of  the  bearing  which  these 
measurements  had  upon  labour,  and  indicated  the  various  ways 
in  which  the  diameters  could  be  estimated.  The  class  then 
broke  up  into  sections  for  the  application  of  principles  which 
had  been  enunciated;  and,  supposing  there  were  a  hundred 
students,  ten  men  went  to  each  of  ten  tables,  and  tested  the 
methods  and  familiarised  themselves  with  the  apparatus.  On 
another  day  the  demonstration  would  consist  of  the  examination 
of  a  large  number  of  slides  under  microscopes,  illustrating  the 
appearances  of  placentas  from  two  months  up  to  the  full  term, 
or  of  the  uterine  musculature  at  various  stages  of  development. 
On  another  day  the  electric  phantom  would  be  brought  into 
action. " 

"  I  beg  your  pardon,"  I  here  interjected ;  "  what  was  the 
electric  phantom  ? " 

"  It  was  a  skilfully  made  model  of  the  abdomen  and  pelvis 
with  the  full-time  uterus  inside.  By  a  somewhat  complex 
apparatus,  a  doll  representing  the  foetus  could  be  expelled  from 
the  interior  through  the  canals,  exhibiting  in  its  progress  the 


10  ADDRESS   ON  THE   FUTURE  OF   OBSTETRICS, 

whole  mechanism  of  labour.  The  rate  could  be  regulated  to  a 
nicety,  so  that  a  twelve  hours'  or  a  twelve  minutes'  labour  could 
be  imitated;  further,  the  process  could  be  interrupted  at  any 
stage  (when  the  head  was  on  the  perineum,  for  instance),  and 
the  details  explained.  A  student  could  be  placed  in  charge  of 
the  phantom  labour  at  any  time,  the  most  favourite  being  of 
course  the  period  of  vulvar  dilatation  and  of  the  passage  of  the 
head ;  if  he  made  any  mistake  in  the  method  he  adopted  for  the 
delivery  of  the  head  and  for  the  safety  of  the  perineum,  he 
could  be  checked  and  shown  the  right  plan.  By  the  touching 
of  a  button  the  pelvis  could  be  narrowed  at  the  inlet  or  outlet, 
or  be  deformed  in  other  ways,  and  by  the  use  of  dolls  of 
various  sizes,  representing  mature,  premature,  and  post-mature 
foetuses,  different  kinds  of  delay  or  varieties  of  mechanism  could 
be  exhibited.  The  dolls'  heads  were  so  constructed  as  to  permit 
the  occurrence  of  moulding." 

"I  can  quite  understand  the  value  of  teaching  such  as 
you  describe,"  I  said  to  Nineteen  Forty;  and  I  suppose  it 
was  supplemented  by  clinical  instruction  in  the  Maternity 
Hospital?" 

"  That,  of  course,"  was  the  reply,  *  and  also  at  the  various 
small  maternity  sub-centres,  scattered  over  all  our  large  cities. 
They  were  sets  of  two  or  three  rooms,  with  accommodation  for  ten 
or  twelve  patients,  under  the  charge  of  an  assistant  obstetric 
officer  and  one  or  two  nurses ;  in  them  normal  or  nearly  normal 
cases  were  confined,  leaving  the  central  institution  for  the  com- 
plicated and  operative  labours.  But  these  were  comparatively 
early  changes  in  our  teaching  methods,"  went  on  my  informant ; 
"  others  soon  followed.  One,  for  instance,  was  the  introduction 
of  the  kinematograph  and  the  gramophone.  By  a  perfecting  of 
the  methods  of  obtaining  differential  radiograms,  it  became 
possible  to  represent  internal  processes,  such  as  the  passage  of  a 
stone  down  the  ureter,  or  of  the  infant  through  the  passages,  by 
the  kinematograph.     The  pictures  thus  obtained  were  thrown 


BY  DR   J.   W.    BALLANTYNE.  11 

upon  the  screen  and  utilised  in  the  teaching  of  obstetrics ;  in 
this  way,  for  instance,  the  mechanism  of  labour  could  be  shown 
and  the  somewhat  cumbrous  and  uncertain  electric  phantom 
replaced.  By  the  gramophone  we  were  able  to  reproduce  and 
illustrate  the  cry  of  the  parturient  woman  in  the  different  stages 
of  labour,  and  the  various  sounds  made  by  healthy,  by  premature, 
and  by  semi-asphyxiated  infants,  as  well  as  by  those  whose 
birth  had  been  accomplished  by  the  use  of  forceps.  The  different 
kinds  of  movement  made  by  the  foetus  in  utero  (rotatory, 
calcitrant,  vibratory,  or  singultant)  could  be  shown  by  the  kine- 
matograph,  while  the  neophone  reproduced  accurately  the  fcetal 
heart  sounds  and  the  uterine  bruit." 

"  Stop !  stop ! "  I  said,  "  I  cannot  follow  you  any  further  in 
your  novelties  of  obstetric  teaching." 

"  I  was  afraid  you  would  begin  to  find  there  were  difficulties 
in  understanding  all  the  details,"  was  my  friend's  reply,  "  and 
yet  I  have  only  begun  to  name  some  of  the  new  methods 
invented  by  science  for  the  imparting  and  for  the  testing  of 
obstetric  knowledge.  I  was  going  on  to  tell  you  of  the  micro- 
kinematograph,  by  which  all  embryological  processes  and 
organogenetic  readjustments  could  be  first  represented  and 
then  reproduced  upon  the  screen  for  teaching  purposes.  I 
intended  then  to  give  you  an  idea  of  the  automatic  and 
registering  gramophone  for  use  at  oral  examinations,  which 
excluded  all  conscious  and  unconscious  bias  in  the  testing  of 
candidates  for  degrees,  for  it  rolled  out  questions  in  an  ex- 
pressionless tone  of  voice,  and  recorded  without  feeling  the 
answers  given  in  reply ;  and  I  was  hoping  to  have  interested 
you  in  the  great  development  of  clinical  teaching  which  took 
place  soon  after  1906,  and  more  especially  after  an  examination 
in  Clinical  Obstetrics  was  insisted  upon  by  nearly  all  universities. 
Perhaps,  however,  it  would  be  well  if  I  passed  on  to  some  other 
subjects,  for,  after  all,  the  advances  in  the  clinical  teaching  of 
Midwifery  were  already  indicated  and  could  be  recognised  and 


12  ADDRESS   ON  THE  FUTURE  OF  OBSTETRICS, 

foretold  by  any  thinking  and  observant  man,  even  at  the  time 
at  which  you  are." 

Obstetrical  Societies. 

"  What,  then,  may  I  ask,  have  you  to  tell  me  about  our  own 
and  kindred  societies  in  the  Twentieth  Century?"  was  the 
next  question  which  I  put  to  Nineteen  Forty. 

"There  was  a  great  and  beneficial  change  in  the  life  and 
activities  of  the  various  learned  societies  in  Edinburgh  soon 
after  1906.  By  means  of  a  munificent  gift  from  a  wealthy 
man  with  strong  scientific  leanings,  a  large  central  hall  to 
serve  as  a  meeting-place  for  all  the  Edinburgh  societies  was 
built.  Our  own  Society  was,  of  course,  one  of  these.  But 
this  was  found  to  be  a  suitable  occasion  for  a  rearrangement 
of  the  energies  and  spheres  of  the  different  learned  bodies, 
and  so  gyntecology  was  united  with  surgery  to  form  a  large 
surgical  society,  the  Obstetrical  Society  devoted  itself  entirely 
to  midwifery,  the  Medico-Chirurgical  Society  became  the  Koyal 
Medical  Society  by  fusion  with  the  old  undergraduate  organisa- 
tion bearing  that  name  (the  surgical  members  of  both  allying 
themselves  with  the  newly  formed  surgical  society),  and  the 
Pathological  Club  increased  its  membership  and  instituted 
Anatomical,  Physiological,  and  Psychological  Sections.  Similarly, 
the  other  scientific  societies  rearranged  themselves.  Each 
society  had  its  own  afternoon  or  evening  in  the  month ;  but,  in 
addition,  there  were  conjoint  meetings  on  special  occasions, 
when,  for  instance,  the  Medical,  Surgical,  and  Obstetrical 
Societies  would  unite  together  for  the  discussion  of  subjects  in 
which  each  had  an  interest.  The  Eoyal  Society  was,  as  it 
were,  the  mother  of  us  all.  Through  the  benefactions  of  the 
generous  donor  already  mentioned,  the  fee  for  membership  was 
made  quite  a  nominal  one,  and  the  member's  ticket  admitted  to 
all  the  meetings,  but  it  only  conferred  powers  of  contributing 
to  or  speaking  at  one  of  the  societies  and  at  the  conjoint  meet- 


BY  DR   J.    W.    BALLANTYNE.  13 

ings  in  which  that  society  took  part.  The  most  wonderful 
part  of  the  hall  of  the  societies  was  the  phonograph  room ;  at 
least  it  will  seem  so  to  you,"  said  my  friend,  Nineteen  Forty. 
u  This  room,"  he  continued,  "  was  in  telephonic  communication 
with  all  the  learned  societies  in  the  world,  and  if  you  wished  to 
hear  the  papers  read  at  different  places  you  had  only  to  switch 
yourself  on  to  any  one  you  might  choose.  In  this  way,  you 
missed  none  of  the  asides  and  interruptions  which  are  so  often 
the  very  soul  and  life  of  a  discussion.  Furthermore,  the 
speaker,  knowing  that  his  words  were  audible  all  over  the  world, 
was  very  careful  as  regards  his  statements,  and  rarely  claimed 
priority  for  any  suggestion,  therapeutic  or  otherwise." 

"  But  what  about  understanding  the  language  in  which  the 
discussion  was  taking  place  ? "  was  the  question  which  I  could 
not  prevent  myself  from  here  asking. 

"You  surely  do  not  think  for  a  moment  that  the  world, 
and  especially  the  scientific  world,  was  content  to  go  on  till 
1940  without  adopting  a  universal  language,"  was  the  answer 
I  received  to  my  question ;  and  I  was  so  taken  aback  by  the 
tone  of  reproach  in  my  friend's  voice  that  I  had  no  remark 
ready,  and  so  lost  my  opportunity  of  finding  out  what  the 
universal  language  was.  Before  I  had  time  to  recover  myself 
I  found  that  Nineteen  Forty  was  beginning  to  describe  to  me 
some  of  the  changes  which  had  taken  place  in  the  practice  of 
midwifery,  and  as  I  did  not  wish  to  miss  anything  of  what  he 
was  saying,  I  had  to  give  him  my  attention, 

Obstetric  Practice. 

"  You  must  know,"  he  was  saying,  "  that  the  discovery 
which  revolutionised  obstetric  practice  in  the  twentieth 
century  was  that  of  a  tocophoric  serum." 

"  What  was  that  ?  "  I  asked. 

"A  serum  obtained  from  the  blood  of  pregnant  animals 
which   had   been  treated   with   cultures   from  the  blood  of   a 


14  ADDRESS   ON  THE  FUTURE  OF  OBSTETRICS, 

human  placenta,  obtained  preferably  from  a  case  of  placenta 
praevia,"  was  the  reply.  "  Its  introduction  into  use  gave  us 
the  means  of  safely,  speedily,  and  certainly  inducing  healthy 
action  of  the  .uterus.  In  this  way  a  labour  could  be  brought 
on  and  a  child  born  with  almost  the  same  degree  of  certainty 
with  which  it  used  to  be  possible  to  perform  a  surgical  opera- 
tion. The  day,  and  in  some  cases  even  the  hour,  could  be 
arranged,  and  a  midwifery  case  became  a  certain  part  of  the 
day's  work  instead  of  an  uncertain  contingency  in  the  middle 
of  any  night.  In  the  nineteenth  century  the  introduction  of 
anaesthesia  abolished  the  pains  of  labour  and  brought  in  a 
new  era  of  obstetric  advance;  in  the  twentieth  century  the 
discovery  of  this  tocophoric  serum  did  away  with  the 
uncertainty  of  the  supervention  of  labour,  and  had  an  almost 
equally  great  influence  upon  our  subject.  The  profession 
earned  the  gratitude  of  countless  patients,  who  said  something 
like  this :  '  In  the  past  you  relieved  our  pains  and  sent  us  to 
sleep  in  the  midst  of  our  agony;  but  now  you  have  released 
us  also  from  the  intolerable  bondage  of  our  uncertainty,  and 
we  thank  you  for  this  new  boon.'  Post-mature  confinements, 
with  their  risks  and  delays,  were  in  this  manner  done  away 
with ;  a  time  suitable  alike  for  patient,  nurse,  and  obstetrician, 
and  calculated  as  accurately  as  possible  to  coincide  with  the 
full  term  of  pregnancy,  was  fixed  upon;  and  the  labour  was 
conducted  with  the  same  care  and  aseptic  precautions  as  a 
gynaecological  or  other  operation." 

"  But  what  about  premature  labours  ? "  was  the  question 
with  which  I  here  checked  my  friend's  flow  of  description. 

"I  expected  that  remark,"  was  his  reply.  'You  must 
know  that  the  special  investigation  given  to  the  pathology 
of  pregnancy  in  the  early  part  of  the  twentieth  century  bore 
good  fruit  in  the  discovery  of  means  of  successfully  preventing 
the  premature  termination  of  pregnancy,  and  such  abnormal 
labours  became  very  rare.     At  the  same  time  the   tocophoric 


BY  DR  J.   W.    BALLANTYNE.  15 

serum  gave  us  a  means  of  interrupting  pregnancy,  when  for 
medical  or  obstetric  reasons  (such  as  pelvic  contractions,  heart 
disease,  etc.)  it  was  regarded  as  desirable  so  to  do." 

The  Falling  Birth-Kate. 

"But  the  great  principle  of  obstetric  practice  in  the 
twentieth  century,"  continued  my  informant,  "  was  the  securing 
of  the  safety  of  the  infant." 

"You  mean,"  I  said,  "that  the  falling  birth-rate  forced 
obstetricians  everywhere  to  reconsider  all  their  methods, 
operative  and  otherwise,  from  the  standpoint  of  the  life  of 
the  infant  ? " 

"Yes,  indeed,"  was  the  reply;  "and  I  shall  now  try  to 
make  this  plain  to  you.  I  must  introduce  some  statistics  to 
bring  out  my  meaning,  but  you,  of  course,  can  take  your  ear 
from  the  instrument  if  you  are  bored." 

"  Truly,  I  shall  do  no  such  thing,"  I  protested. 

"In  1906  the  falling  birth-rate  in  our  own  and  in  all 
civilised  lands  was  at  length  beginning  to  attract  the  attention 
it  deserved.  The  birth-rate  for  England  and  Wales  was  35*2 
for  the  decade  1865-1874;  it  was  347  for  the  next  decade; 
for  the  next  period  of  ten  years  (1885-1894)  it  had  fallen  to 
31'2;  and  during  the  last  ten  years  (1895-1904)  it  has  sunk 
to  29*0.  So  much  for  England  and  Wales.  Sir  Henry 
Littlejohn  had  a  still  more  depressing  account  to  give  of 
the  capital  of  Scotland.  In  1871  the  natality  in  Edinburgh 
was  34*8  (almost  the  same  as  that  of  England  and  Wales  at 
the  same  time) ;  in  1881  it  was  32'2 ;  in  1891,  28'2 ;  in  1901, 
24-99;  and  in  1905  it  was  22-99.1     Even   with   these   figures 

1  The  figures  for  1906  are  now  available  :  the  number  of  births  was 
7042,  and  the  birth-rate  was  22'41  per  1000.  The  descent,  therefore, 
is  steadily  going  on,  and  the  number  of  babies  born  in  1906  is  actually 
less  than  the  number  in  1881,  although  the  population  has  so  greatly 
increased. 


16  ADDRESS   ON   THE  FUTURE  OF  OBSTETRICS, 

before  you  the  full  gravity  and  meaning  of  the  position  was 
not  recognised  in  1906.  In  order  to  grasp  the  significance  of 
the  movement,  look  at  the  matter  thus.  In  1881,  when  the 
population  of  Edinburgh  was  (in  round  figures)  228,000,  the 
number  of  babies  born  was  7360 ;  in  1905,  when  the  population 
had  increased  to  336,000,  the  number  of  babies  born  was  7741, 
whereas,  if  the  rate  had  been  maintained,  it  ought  to  have  been 
10,846.  There  was  therefore  a  shortage  of  over  3000  babies. 
It  is  only  fair  to  the  country  in  general  to  state  that  Edinburgh 
occupied  almost  the  worst  position  in  this  matter  of  a  falling 
birth-rate.  Of  the  sixteen  large  towns  of  England  and 
Scotland,  there  was  only  one  (Bradford)  that  had  a  lower 
birth-rate  than  Edinburgh;  and  while  London  registered  27, 
Dundee  had  28,  Manchester,  Birmingham,  Aberdeen,  and 
Leith  had  29,  Glasgow  and  Greenock  had  30,  and  Liverpool 
had  33." 

"  But,"  I  here  interruped,  as  my  friend  paused  to  note  the 
effect  of  these  undeniably  startling  figures,  "the  death-rate 
had  fallen  as  well  as  the  birth-rate,  and  so  we  were  no  worse 
than  we  were  before." 

"  Let  us  take  the  Edinburgh  statistics  again,"  was  the  reply. 
"In  1881  the  death-rate  was  1886;  in  1905  it  was  1425,  the 
lowest  ever  reached  till  then.  While,  however,  the  death-rate 
was  slowly  falling  from  18  to  14,  the  birth-rate  had  come 
rapidly  down  from  32*23  to  22*99.  If  this  rate  of  descent  had 
in  each  case  been  maintained  for  another  quarter  of  a  century 
the  two  rates  would  have  reached  almost  the  same  figure,  and 
any  increase  in  the  population  of  Edinburgh  would  have  had 
to  be  put  down  to  immigration,  for  the  birth-rate  had  been 
falling  much  more  quickly  than  the  death-rate.  Further,  while 
it  was  conceivable  that  the  natality  of  Edinburgh  would 
continue  to  fall  till  it  reached  a  vanishing  point,  it  was 
not  thinkable  that  its  mortality  would  do  likewise.  There 
might   come   a  year  when  there  were  no  births,  but  it  could 


BY  DR   J.    W.    BALLANTYNE.  17 

hardly  be  expected  that  in  that  year  there  would  occur  no 
deaths.  All  these  things,  however,  were  to  the  inhabitants  of 
Edinburgh  in  1906  as  idle  tales;  they  heeded  them  not.  And 
yet,  to  Edinburgh  obstetricians  at  least,  the  subject  of  the 
falling  birth-rate  was  a  grave  problem,  and  it  became  no 
less  grave  as  the  twentieth  century  proceeded  on  its  way.  To 
put  the  matter  very  practically,"  said  Nineteen  Forty,  "there 
were  many  more  doctors  settled  in  Edinburgh  in  1906  than  in 
1881,  but  the  number  of  babies  being  born. was  practically  the 
same.  I  expect  some  of  you  had  shrinking  lists  of  midwifery 
engagements  to  deplore,  but  I  forbear  to  press  the  point." 

"  Can  you  give  me  now  any  hints  as  to  the  way  in  which 
obstetricians  in  the  twentieth  century  met  the  dangers  of  the 
falling  birth-rate  ? "  was  my  next  question. 

"That  I  will  gladly  do,"  was  my  friend's  answer;  "but, 
first,  I  must  point  out  what  perhaps  was  little  recognised  or 
altogether  overlooked  in  1906.  I  refer  to  the  aggravations  of 
the  falling  birth-rate." 

The  Aggravations  of  the  Falling  Birth-Kate. 

"  What  were  these  aggravations  ? "  I  asked. 

"In  the  first  place,  there  was  the  infantile  death-rate. 
You  were  proud,  in  1906,  of  the  fall  that  had  taken  place  in 
the  general  death-rate  of  the  country  during  the  preceding 
half  century,  and  your  pride  was  justified;  for  there  had 
been  a  reduction  by  more  than  fifty  per  cent,  of  the  number 
of  deaths  between  the  ages  of  five  and  twenty-five  years, 
and  between  twenty-five  and  thirty-five  there  had  also  been 
a  notable  decrease.  But  there  was  one  circumstance  about 
which  little  was  said,  and  about  which  no  pride  could  be  felt : 
the  infantile  death-rate  was  practically  unchanged  at  the  end 
of  these  fifty  years  of  hygienic  progress  and  material  advance- 
ment.    To  quote  from  the  Report  of  the  National   Conference 

B 


18  ADDRESS   ON   THE   FUTURE   OF   OBSTETRICS, 

on  Infantile  Mortality  (p.  99),  held  in  London  in  June  1906 : 
'In  the  twenty  years  ended  1874,  we  find  that  out  of  every 
1000  children  born  alive  in  England  and  Wales,  153  never 
completed  their  first  year,  while  in  the  twenty  years  ended 
1904,  the  ratio  was  148  per  1000.'  There  was,  it  is  true, 
a  slight  improvement — 148  instead  of  153 — but  was  it  an 
adequate,  a  satisfactory,  even  a  noteworthy  degree  of  improve- 
ment, when  contrasted  with  the  fifty  per  cent,  improvement 
between  the  ages  of  five  and  twenty-five?  This,  then,  I 
call  the  first  aggravation  of  the  falling  birth-rate :  fewer  babies 
were  being  born,  and  yet  they  were  dying  off  practically  as 
rapidly  during  the  first  year  of  life  as  they  had  ever  done. 

"A  second  aggravation  was  your  ignorance,  in  1906,  of 
the  stillbirth-rate  and  the  abortion-rate  of  your  country.  You 
did  not  know  how  many  pregnancies  ended  in  the  birth  of 
infants  who  never  lived  outside  the  mother's  uterus,  who, 
in  the  words  of  one  of  the  nineteenth  century  poets,  exchanged 
cthe  amnios-skin  of  this  world  for  the  shroud,  the  amnios- 
skin  of  the  next.'  You  hoped,  perhaps,  that  fewer  stillbirths 
were  happening,  but  you  dreaded  lest  your  hopes  should  turn 
out  ill-founded ;  at  any  rate  you  did  not  know,  for  there  was 
no  registration  of  stillbirths  to  reveal  the  frequency  of 
such  ante-natal  catastrophes.  In  reality,  a  steady  increase 
was  going  on,  as  Dr  Kaye's  Yorkshire  statistics,  local  though 
they  were,  proved.  He  found  that  in  1901  there  were  47*6 
stillbirths  per  1000  livebirths,  and  the  number  steadily 
increased  until  in  1905  it  was  56*3.  'Apply  these  figures/ 
said  Dr  Kaye  {Report  of  the  National  Conference  on  Infantile 
Mortality,  1906,  p.  104),  'to  the  whole  country  (England  and 
Wales),  and  it  means  that  the  number  of  stillbirths  has  grown 
from  44,270  in  1901  to  52,350  in  1905,  an  increase  of  over  18 
per  cent.,  while  the  total  livebirths  have  decreased  in  actual 
numbers/  Then  as  to  the  abortion-rate,  you  must  surely," 
said  the  Official  of  1940,  ''  have  had  some   feelings  of  dismay 


BY  DR   J.    W.    BALLAD  TYKE. 


19 


when,  in  1906  and  in  preceding  years,  you  reflected  upon  the 
wastage  of  ante-natal  life  by  reason  of  abortions.  You  could 
hardly  shut  your  eyes  to  and  stop  your  ears  against  the 
testimony  of  text-books  and  journal  articles  which,  with 
striking  unanimity,  attested  the  frequency,  the  growing 
frequency,  of  abortion.  Some  placed  the  frequency  of  mis- 
carriage at  one  to  every  three  or  four  pregnancies;  others 
stated  that  one  in  every  five  gestations  ended  in  abortion." 

Here  I  interrupted  my  informant  with  the  remark  that 
I  did  not  think  the  abortion-rate  was  so  high  as  that. 

"  What  reasons  have  you  for  doubting  it  ? " 

"Well,"  was  my  reply,  "in  the  last  series  of  100  indoor 
labours  under  my  care  in  the  Edinburgh  Eoyal  Maternity 
Hospital  there  were  not  many  women  who  gave  a  history 
of  having  aborted." 

"But,"  said  my  friend,  "did  you  exclude  the  primiparas 
and  the  women  under  thirty  years  of  age  ? " 

"  No,"  I  replied. 

"  Suppose  you  do  that ;  how  do  your  statistics  stand  now  ?  " 

"In  the  100  cases  there  were  21  women  of  thirty  years  of 
age  and  over,  and  of  them  8  gave  a  history  of  previous 
abortions." 

"  There  you  are,"  said  Nineteen  Forty  in  triumph ;  "  thirty- 
eight  per  cent,  of  your  patients  who  had  reached  the  middle 
of  reproductive  life  had  aborted !  Besides,"  he  continued, 
"you  had  only  the  patients'  word  for  the  number  of  their 
abortions;  it  is  much  more  likely  that  they  under-estimated 
than  over-estimated  the  frequency  of  such  occurrences,  especially 
early  miscarriages  of  six  weeks.  You  must,  after  all,  admit 
that  not  fewer  but  more  abortions  were  occurring  in  Great 
Britain  in  the  early  years  of  the  twentieth  century.  There 
was  yet  another  aggravation  to  the  falling  birth-rate,  to  which 
I  must,  for  a  moment,  refer.  That  was  the  curiously  significant 
increase  in  the  number  of  deaths  ascribed  to  premature  birth 


20  ADDRESS   ON   THE  FUTURE   OF   OBSTETRICS, 

which  began  to  be  noticeable  in  the  mortality  returns.  The 
infantile  mortality  from  premature  birth,  which  in  1865-1874 
was  11-9  per  1000  (for  England  and  Wales),  had  in  1875-1884 
grown  to  13-7,  in  1885-1894  to  168,  and  in  1895-1904  to  198. 
The  most  striking  thing  about  this  increase  was  that  it  began 
as  soon  as  and  no  sooner  than  the  birth-rate  commenced 
to  decline.  One  can  hardly  refuse  to  ascribe  some  significance 
to  that  fact. 

"Now,  let  me  gather  together  these  various  statements," 
said  Nineteen  Forty,  "and  you  will  see  better  how  you  really 
stood  in  the  year  in  which  you  are  living.  The  infantile 
death-rate,  notwithstanding  all  recent  advances  in  hygiene 
and  the  laborious  study  of  the  diseases  of  infancy,  was  no 
better  than  it  was  fifty  years  previously.  There  was  reason 
to  believe  that  the  number  of  stillbirths  and  abortions 
was  increasing;  and  these,  although  they  constituted  deaths 
in  a  real  sense  if  not  in  a  forensic  one,  were  not  included 
in  the  mortality  tables.  The  number  of  infantile  deaths 
ascribed  to  premature  birth  was  increasing,  pointing  to  a 
probable  increase  in  the  total  number  of  premature  births 
occurring.  Finally,  there  was  the  progressive  and  serious 
fall  in  the  birth-rate.  What  could  the  obstetricians  of  the 
twentieth  century  do  but  strive  to  counteract  these  evils  ? " 

Checking  the  Falling  Birth-Eate. 

"  How  did  they  check  the  falling  birth-rate  ? "  was  my 
question,  for  my  informant  at  this  stage  in  our  conversation 
seemed  to  expect  me  to  say  something. 

"  They  did  not  check  it,  they  could  not  check  it,"  was 
the  startling  reply;  "but  they  checked  the  aggravations 
of  it,  and  so  secured  some  salvage  from  the  wreckage  of 
life  which  was  occurring  before,  at,  and  immediately  after 
birth.     This   salvage   more   than   compensated  for  the  decline 


BY  DR  J.    W.    BALLANTYNE. 


21 


in  the  birth-rate,  and  thus  the  civilised  nations  of  the  earth 
were  able  to  maintain  their  position  to  some  extent,  at  any 
rate,  if  not  entirely.  So  now  you  see  why  I  so  strongly 
emphasised  the  aggravations  of  the  falling  birth-rate.  But 
matters  got  much  worse  before  they  began  to  improve." 

"  In  what  way  ? "  I  asked. 

"  I  will  tell  you,"  was  the  reply. 

"  The  checking  of  the  falling  birth-rate  was,  as  I  have  said, 
not  an  obstetrical  problem  at  all ;  at  least  it  was  not  one  which 
obstetricians  could  hope  to  solve.  The  falling  of  the  birth-rate 
was  not  due  to  less  knowledge  or  less  skill  in  the  obstetricians 
of  the  day,  or  to  want  of  training  of  the  midwives  and  monthly 
nurses,  or  to  the  neglect  of  chloroform  or  the  forceps,  or  to 
the  excessive  use  of  these  means  of  relieving  pain  and  hastening 
the  second  stage  of  labour,  or,  indeed,  to  any  other  thing  which 
lay  in  the  power  of  the  medical  man  to  do  or  leave  undone. 
The  causes  lay  deep  among  the  roots  of  the  somewhat  artificial 
conditions  of  the  sexual  relationships  in  modern  society.  A 
nineteenth  century  writer  (Kenan)  said :  '  The  spread  of  an 
enlightened  selfishness  is,  in  the  moral  world,  a  fact  of  the 
same  nature  as  the  exhaustion  of  coal-fields  in  the  physical 
world;  in  each  case  the  existing  generation  is  living  upon 
and  not  replacing  the  economies  of  the  past.'  His  words 
apply  very  exactly  to  the  enlightened  selfishness  which  was 
the  root-cause  of  the  falling  birth-rate.  The  era  of  personal 
comfort  first,  and  at  any  cost ;  the  age  of  late  marriage,  because 
the  entrants  upon  the  matrimonial  state  wished  to  begin,  not 
where  their  parents  began,  but  where  they  were  prepared  to 
leave  off;  the  period  of  frequent  holidays  and  expensive 
amusements  could  hardly  be  described  as  other  than  '  selfish/ 
although  it  might  be  doubted  whether  it  deserved  the  honour 
of  being  entitled  '  enlightened.'  In  any  case,  such  an  age  was 
not  one  in  which  frequent  child-bearing  was  likely  to  be 
thought  of  with  favour,  or  carried  through  with   enthusiasm. 


22  ADDRESS   ON   THE   FUTURE   OF   OBSTETRICS, 

If  there  was  ergophobia  in  the  one  sex,  there  was  maieusophobia 
in  the  other.  Nor  was  a  popularisation  of  the  knowledge 
of  the  nature  and  mode  of  use  of  '  checks '  to  conception  likely 
to  raise  the  average  size  of  families. 

"Matters  did  not  improve  after  1906.  In  fact,  it  was  not 
long  till  rumours  began  to  circulate  regarding  the  existence 
of  a  new  institution,  the  '  City  without  a  Child,'  a  sort  of 
municipal  agennesia,  wherein  mental  productivity  and  financial 
success  were  held  in  high  esteem,  while  the  reproduction  of  the 
race  was  nothing  accounted  of.  The  inhabitants  renounced  the 
pleasure  and  the  honour  of  having  families,  but  gladly  accepted 
all  other  pleasures  and  honours  that  came  in  their  way.  The 
citizens  occupied  their  days  in  making  money,  and  their  nights 
were  not  spent  round  the  fireside  in  the  home.  They  were 
described  as  curious  places,  these  experimental  childrenless 
cities :  no  schools,  no  toy-shops,  no  Christmas-trees,  no  happy 
young  boys  and  girls  on  the  roadways;  nothing  but  hard- 
visaged  men  and  steel-eyed  women,  and  bustle  and  racket,  and 
vain  hopes  and  restless  desires;  and  by-and-by  an  alarming 
increase  in  the  frequency  of  suicide,  and  in  the  number  of  the 
inmates  of  the  palatial  asylum  which  stood  upon  a  hill 
overlooking  the  town.  So,  in  the  end,  the  attempt  to  reduce 
the  birth-rate  to  nil  was  the  cause  of  its  gradual  ascent  again  ; 
and  the  experiment  of  race-suicide  was  in  that  sense  a  failure. 

"In  the  meantime  the  medical  profession,  and  especially 
the  obstetricians,  had  been  busily  endeavouring  to  save  some- 
thing from  the  wastage  of  ante-natal  life,  and  to  keep  alive 
many  of  the  new-born  infants  who  formerly  used  to  succumb 
to  death  in  various  forms  during  the  first  few  months  of  post- 
natal existence." 

Estimation  of  the  Wastage  of  Ante-natal  Life. 
"In  the  first  place,"  continued  the  Official  of    1940,  "the 


BY  DB  J.   W.    BALLANTYNE.  23 

obstetricians  of  the  early  part  of  the  twentieth  century  set 
themselves  the  task  of  estimating  the  annual  loss  of  life  at 
and  before  birth.  With  the  help  of  a  Stillbirth  Eegistration 
Act,  and  with  the  assistance  of  the  army  of  skilled  monthly 
nurses  which  the  Mid  wives  Bill  had  called  into  being,  statistics 
of  stillbirths  and  abortions  were  obtained.  The  results  were 
startling,  appalling  in  fact;  but  after  the  first  excitement 
incident  thereupon  had  died  down,  it  was  seen  that  in  the  very 
magnitude  of  the  loss  of  ante-natal  life  that  had  been  going  on 
lay  the  hope  of  the  future.  By  diminishing  the  ante-natal 
death-rate,  by  checking  the  frequency  of  abortion,  it  was 
recognised  that  there  was  a  means  ready  to  hand  to  counter- 
balance the  falling  birth-rate.  If  a  fifth  of  the  stillbirths  and 
abortions  could  be  prevented,  it  was  seen  that  the  loss  accruing 
from  the  smaller  number  of  births  would  be  compensated. 
Further,  it  was  discovered  that  many  of  the  cases  which  went 
to  produce  the  high  infantile  mortality  of  148  per  1000,  during 
the  first  year  of  life,  were  deaths  of  prematurely  born  infants. 
So  it  became  apparent  that  to  check  the  frequency  of  premature 
births  would  give  a  means  of  reducing  the  high  infantile  death- 
rate;  in  this  direction  also  there  lay  compensation  for  the 
failing  birth-rate.  You  can  almost  forecast  for  yourself  now 
the  lines  along  which  obstetric  practice  began  to  advance,"  said 
my  friend  of  1940;  "but  I  will  indicate  them  very  briefly." 

Study  of  Pregnancy,  Normal  and  Pathological. 

"  The  hygiene  of  pregnancy  began  to  be  studied  in  detail  and 
with  an  enthusiasm  and  thoroughness  never  before  arrived  at. 
Patients  were  encouraged  to  consult  their  medical  attendants 
regarding  the  rules  of  health  in  pregnancy,  and  the  latter  were 
prepared  to  give  the  advice  sought.  It  was  recognised  that 
pregnancy  was  a  severe  and  a  long-continued  testing  of  the 
structural   and   functional   integrity   of    all   the   organs   of    a 


24  ADDRESS   ON   THE   FUTURE   OF   OBSTETRICS, 

woman's  body.  It  was  soon  seen  that  while  an  unmarried  or 
a  non-pregnant  woman  might  with  impunity,  or  apparent 
impunity,  break  many  of  the  laws  of  hygiene,  a  pregnant 
patient  did  so  at  her  peril ;  and  every  medical  man  made  it  his 
duty  to  revise  with  the  pregnant  patients  all  the  rules  relating 
to  the  care  of  the  bodily  functions,  putting  right  what  was 
wrong,  and  warning  against  possible  errors  in  diet,  clothing, 
habits,  and  the  like. 

"Further,  in  cases  of  doubt,  consultations  were  freely  asked 
for  and  given,  it  being  recognised  that  it  was  better  to  check 
the  beginnings  of  evils  in  pregnancy  than  to  wait  till  an 
abnormal  gestation  had  developed  into  a  labour  dangerous  for 
infant  and  mother  alike.  Whereas  in  your  time,"  said  my 
informant,  "  consultations  in  pregnancy  were  seldom  asked  for, 
save  to  determine  whether  the  induction  of  abortion  should  be 
carried  out  in  order  to  try  to  save  the  mother's  life  at  the 
expense  of  that  of  her  foetus,  in  the  new  era  the  specialist  was 
called  in  early  enough  for  his  remedial  measures  to  avail  both 
the  maternal  and  the  infantile  lives.  In  this  way,  not  only 
were  pathological  pregnancies  often  prevented  altogether,  but 
in  many  instances  they  were  so  energetically  treated  in  the 
early  phases  that  they  yielded  to  therapeutic  means  that  would 
have  been  of  no  use  at  later  stages.  Eclampsia  was  one  of  the 
first  of  the  gestational  maladies  which  began  to  benefit  by  such 
a  revolution  in  the  management  of  pregnancy.  Whereas  it  had 
been  common  for  the  urine  of  a  pregnant  patient  never  to  be 
tested — indeed,  in  many  cases  it  was  not  customary  for  the 
medical  attendant  to  be  told  about  the  pregnancy  or  summoned 
to  the  patient  till  labour  was  in  the  first  stage — now,  the  doctor 
was  engaged  to  look  after  his  patient  in  the  early  weeks  of  her 
pregnancy  as  well  as  in  the  hours  of  her  labour  and  in  the  days 
of  her  puerperium.  His  duties  included  regular  analysis  of  the 
urine,  as  well  as  the  supervision  of  all  the  details  of  the  gesta- 
tion, and  the  correction  of  any  of  the  symptoms  which  might 


BY   DR   J.    W.    BALLANTYNE. 


25 


arise.  The  obstetrician  of  1940  finds  it  difficult  to  understand 
why  his  brethren  of  the  early  part  of  the  century  paid  so  much 
attention  to  the  one  month  of  the  puerperal  period  and  so  little 
to  the  nine  months  of  pregnancy.  To  him  the  time  of  pre- 
paration for  labour  was  not  less  but  more  important  than  the 
time  of  recovery  from  the  effects  of  labour,  for  he  found  that  if 
the  former  was  normal  the  latter  was  little  likely  to  be 
pathological. 

"  Along  with  this  development  of  the  study  of  the  manage- 
ment of  pregnancy  and  of  the  treatment  of  the  disorders  of 
the  pregnant  state  came  a  marked  advance  in  the  knowledge  of 
ante-natal  maladies.  The  mystery  of  trans-placental  trans- 
mission was  elucidated,  and  stillbirth  by  reason  of  foetal  diseases 
and  defects  became  rare.  So-called  'habitual'  abortion  and 
intra-uterine  death  were  soon  shown  to  be  due  in  every  instance 
to  some  definite  and  ascertainable  cause ;  and  the  hopelessness 
which  had  previously  characterised  all  attempts  at  treatment 
gave  way  to  the  enthusiasm  inspired  by  frequent  success. 
New  and  more  effective  means  of  keeping  prematurely  born 
infants  alive  were  adopted  with  the  best  results,  and  the 
favourite  British  operation  of  the  induction  of  premature 
labour  for  contracted  pelvis  took  an  enhanced  position  of 
esteem  among  other  methods  of  obstetric  intervention.  As  I 
have  already  said,  the  appreciation  of  the  value  of  foetal  life 
was  the  fact  which  dominated  obstetric  theory  and  practice  in 
the  twentieth  century.  Embryulcia,  craniotomy,  and  all  such 
destructive  procedures  yielded  to  methods  which  gave  a  chance 
of  survival  to  the  child,  and  thus  Cesarean  Section,  Vaginal 
Section,  and  the  Induction  of  Premature  Labour  took  their 
rightful  place  in  the  list  of  obstetric  operative  measures.  By 
means  of  the  knowledge  which  obstetricians  gained  regarding 
the  state  of  their  pregnant  patients  {eg,  by  pelvimetry, 
physical  examinations,  etc.)  it  was  possible  to  detect  pelvic 
contractions,  tumours,  and  the  like  before  the  supervention  of 


26  ADDRESS    ON   THE   FUTURE   OF   OBSTETRICS, 

labour,  and  so  to  avoid  interference  at  the  time  when  the 
occurrence  of  the  phenomena  of  childbirth  was  the  cause  of 
additional  risk  and  danger.  For  instance,  it  became  rare  for 
a  medical  man  to  be  summoned  to  a  full-time  labour  in  which 
there  was  an  undetected  pelvic  contraction,  and  thus,  emergency 
Cesarean  Sections  or  (worse  still)  craniotomies  were  hardly 
ever  heard  of." 

The  Problem  of  Cancer. 

"  I  have  greatly  benefited  by  what  you  have  told  me,"  I  said 
to  Nineteen  Forty;  "but  can  you  satisfy  my  curiosity  about 
one  other  matter  ?  It  is  scarcely  an  obstetric  problem,  perhaps, 
but  it  is  a  very  pressing  one :  I  refer  to  the  discovery  of  the 
cause  and  cure  of  cancer." 

"  I  cannot  reveal  much,"  was  the  reply,  "  but  I  am  permitted 
to  throw  out  some  hints.  For  instance,  it  was  not  long  after 
1906  that  it  came  to  be  recognised  that  there  was  a  curious 
parallelism  between  great  philanthropic  movements  and  note- 
worthy life-saving  and  pain-relieving  discoveries." 

"  What  do  you  mean  ? "  I  queried.  "  Well,  take  the  case  of 
the  abolition  of  slavery  in  the  British  possessions  at  a  cost  of 
£20,000,000 ;  that  was  a  great  and  a  beneficent  and  an  unselfish 
act  on  the  part  of  one  section  of  mankind  for  the  amelioration 
of  the  condition  of  another  and  a  suffering  section ;  it  was  soon 
followed  by  the  discovery  of  anaesthesia — that  priceless  boon. 
Of  course,  the  anaesthetics  themselves  had  been  in  existence  for 
years,  but  their  effects  were  till  then  unknown." 

"I  think  I  see  what  you  mean,"  I  said;  "and  was  there 
any  great  philanthropic  advance  pending  in  1906,  or  soon  there- 
after, which  made  it  possible  for  the  discovery  of  the  cause 
and  cure  of  cancer  to  take  place  as  a  corollary  thereto  ? " 

My  friend  hesitated  a  little  before  he  replied,  and  then  said 
slowly:    "The  greatest  boon  that  mankind  could    voluntarily 


BY  DR  J.   W.   BALLANTYNE. 


27 


bestow  upon  itself  would  be  the  abolition  of  war,  would  it 
not  ? " 

"  You  think,"  said  I,  "  that  it  was  that  great  international 
blunder — the  appeal  to  arms  to  settle  disputes — that  was 
delaying  the  discovery  of  the  cure  of  cancer  ? "  My  informant 
did  not  answer  this  question;  at  least,  if  he  did,  I,  in  my 
excitement,  failed  to  catch  his  reply.  So  I  went  on  and  said 
to  him :  "  I  myself  have  of  late  years  been  inclined  to  look  to 
the  chorion-epithelioma  and  its  embryological  relations  for  the 
elucidation  of  the  problem  of  the  origin  of  malignancy ;  but  I 
have  a  friend  who  believes  that  the  secret  lies  in  the  hands  of 
the  botanists.  He  is  sure  that  in  the  differences  of  the  life- 
conditions  of  fungi  and  bacteria  are  to  be  found  the  explanation 
of  the  origin  and  the  theory  of  the  cure  of  cancer." 

"  Tell  him  to  make  experiment,"  was  the  reply  which  came 
to  me  somewhat  indistinctly,  for  it  appeared  as  if  my  telephone 
were  not  recording  very  clearly.  I  spoke  again,  but  it  seemed 
as  if  the  connection  had  been  cut ;  so,  as  I  did  not  wish  to  be 
rude,  I  asked  for  the  Time  Exchange,  No.  1940,  and  got 
switched  on  again.  "  I  wished  to  thank  you  very  warmly  for 
so  kindly  giving  me  so  much  information  about  the  future," 
I  said.  uCan  you  answer  one  other  question,  a  personal 
one  ? "  I  asked.  "  You  described  yourself  at  the  beginning  of 
our  conversation  as  an  Official  of  the  Obstetrical  Society  of 
1940 ;  can  you  give  me  no  other  clue  to  your  identity? " 

"  I  am  the  President,"  was  the  reply. 

"  Indeed,  then,"  I  said,  "  I  am  highly  honoured,  sir,  to  have 
made  your  acquaintance." 

I  heard  what  sounded  like  a  laugh,  and  then  this  rejoinder 
came  back  to  me  over  the  wires :  "  You  call  me  sir,  but  is  it 
impossible  that  the  President  of  1940  should  be  a  woman  ? " 

I  awoke  with  a  start,  to  find  my  telephone  ringing  furiously ; 
and  a  call  to  a  serious  case  at  the  Maternity  Hospital  was  soon 
engaging   my   thoughts.      But   I    have    sometimes    wondered 


28     MANAGEMENT   OF   DIFFICULT   OCCIPITO-POSTERIOR   CASES, 

whether  it  was  all  a  dream;  whether  it  was  not  in  part  an 
"  uprush  of  the  subliminal  consciousness/'  as  the  psychologists 
call  it ;  whether  it  was  not,  in  certain  details,  a  vision  of  that 
future  so  rapidly  advancing  upon  us,  when — 

Much  that  is  wrong  shall  be  righted, 
And  man  shall  see,  never  affrighted, 

Clearly  his  duty,  and  do  it, 

E'en  if  his  life-blood  go  to  it. 


On  the  motion  of  Br  Ritchie,  seconded  by  Br  Craig,  a  hearty 
vote  of  thanks  was  unanimously  accorded  the  President  for  his 
address. 


V.   THE   MANAGEMENT   OF   SOME    DIFFICULT 
OCCIPITO-POSTERIOR  CASES. 

By  J.  Lamond  Lackie,  M.D.,  F.R.C.P.  Ed.,  Assistant  Physician,  Royal 
Maternity  Hospital ;  Lecturer  on  Obstetrics  and  Gynaecology, 
School  of  Medicine  of  the  Royal  Colleges. 

Until  quite  recently,  I  had  been  in  the  habit  of  thinking, 
and  indeed  sometimes  of  teaching,  that  when  the  obstetric 
forceps  slipped  off  the  head  during  the  operation  of  extraction, 
the  instrument  had  been  unskilfully  applied.  "Within  the  last 
month  I  have  changed  my  views  on  this  point  entirely.  Up 
till  October  of  this  year  I  had  no  personal  experience  of  the 
accident,  but  during  that  month  I  had  two  consecutive  cases 
in  which  the  forceps  slipped,  and  these  form  the  basis  of  the 
present  communication. 

Case  I. — Mrs  D.,  set.  29,  primipara,  went  into  labour  on 
Thursday,  4th  October,  at  2  A.M.  The  pains  at  first  were  slight 
and  very  occasional,  but  the  membranes  ruptured  at  10  A.M. ; 
and  at  11  A.M.,  when  I  first  saw  her,  the  os  was  only  the  size 


BY  DR   J.    LAMOND   LACKIE. 


29 


of  a  shilling.  It  dilated  very  slowly,  and  little  progress  was 
made  all  Friday.  During  the  night  the  pains  were  stronger, 
and  at  10  a.m.  on  Saturday  the  os  was  3  inches  in  diameter, 
and  a  right  occipito-posterior  position  was  diagnosed.  Pains 
were  strong  till  3  p.m.,  but  on  examination  one  found  that 
since  10  a.m.  absolutely  no  progress  had  been  made,  and  the 
anterior  segment  of  the  cervix  had  become  oedematous.  At 
4  p.m.  the  patient  was  exhausted,  and  inertia  uteri  had  set  in. 
Chloroform  was  administered,  and  the  dilatation  of  the  os 
completed  by  the  fingers.  Forceps  were  then  applied  to 
the  head,  which  was  well  engaged  in  the  pelvic  inlet.  Strong 
traction  seemed  to  make  no  impression,  and  suddenly,  during 
an  extra  effort  on  my  part,  the  forceps  came  away  in  my  hands. 
The  sensation,  to  say  the  least  of  it,  was  unpleasant ;  one  felt 
that  one  had  fractured  or  dislocated  something,  but  I  take  it 
that  the  click  one  feels  and  hears  is  simply  due  to  the  sudden 
excessive  overriding  of  the  cranial  bones  which  the  closed 
forceps  causes  as  the  instrument  comes  over  the  head.  For- 
tunately, the  damage  to  the  mother's  soft  parts  was  slight,  but 
the  vulva  was  somewhat  torn  by  the  escaping  forceps.  I  then 
tried  to  flex  the  head  and  rotate  it,  but,  as  I  almost  expected, 
my  efforts  were  fruitless,  as  the  head  was  too  high  up  and  too 
fixed.  Forceps  were  again  applied,  and  appreciating  the  fact 
that  the  occiput  was  to  the  back,  I  endeavoured  to  apply  the 
blades  in  that  region.  Again  the  forceps  slipped  when  I 
pulled,  and  this  not  once  but  several  times.  The  instrument 
was  not  each  time  forcibly  pulled  out  of  the  vagina,  as  I  was 
always  on  the  outlook  for  slipping.  Here,  I  may  say,  that  by 
grasping  the  application  handles,  as  well  as  the  traction  handle, 
I  was  better  able  to  appreciate  whether  the  blades  were  to 
slip  or  not;  one  seemed  to  be  more  in  sympathy  with  the 
position  of  the  blades  by  sensation  conveyed  through  the 
handles  than  through  the  traction  rods.  Ultimately,  one 
seemed  to  find  a  grip  that  held,  well  back  over  the  occiput, 


30     MANAGEMENT   OF   DIFFICULT   OCCIPITO-POSTERIOR    CASES, 

and  the  head  was  born  face  to  pubis,  but  only  with  great 
difficulty,  and  after  the  expenditure  of  much  force  in  traction. 
There  was  some  laceration  of  the  perinseum.  The  child,  a 
female,  which  weighed  9  lbs.,  was  apnceic,  but  recovered,  though 
it  showed  signs  of  compression  for  two  or  three  days.  It  is 
now  very  well,  but  has  a  marked  internal  strabismus  of  the 
right  eye,  which,  however,  is  now  improving.  The  mother  had 
a  normal  puerperium.  I  ought  to  mention  that  she  was  a 
woman  of  average  stature,  and  there  were  no  obvious  signs  of 
any  deformity  of  the  pelvis.  This,  then,  was  simply  a  per- 
sistent occipito-posterior  case,  delivered  in  the  usual  way  by 
forceps — the  only  peculiarity  being  the  slipping  of  the  forceps, 
which  shows  how  excessive  was  the  traction  necessary  for 
delivery.  I  have  quoted  the  case  as  a  contrast  to  the  two 
which  follow. 

Case  II. — Mrs  W.,  set.  30,  ii.-para,  expected  her  confinement 
on  10th  October,  but  this  did  not  take  place  till  28th  October. 
Pains  commenced  at  2  a.m.  ;  at  4  A.M.,  when  I  saw  her,  the  os 
was  nearly  but  not  quite  fully  dilated.  Eight  occipito-posterior 
was  the  position.  At  5  A.M.  the  membranes  ruptured  and  the 
liquor  amnii  began  to  trickle  away.  The  cervix  was  still  not 
fully  taken  up.  At  8.30  a.m.  there  was  no  change,  except  that 
the  anterior  segment  of  the  cervix  had  become  oedematous. 
Pains  were  now  slight,  and  made  no  impression  on  the  advance 
of  the  head,  which  remained  at  the  brim.  Under  chloroform, 
forceps  were  applied,  and,  to  my  surprise,  I  repeated  my 
experience  of  6th  October.  The  forceps  came  away  in  my 
hands  with,  fortunately,  no  damage  to  the  mother.  I  reapplied 
them,  still  remembering  the  position  of  P.O. P.,  but  the  result 
was  the  same,  and  no  matter  how  carefully  I  applied  the 
instrument  well  back  towards  the  promontory  of  the  sacrum, 
the  forceps,  whenever  traction  of  any  degree  was  employed, 
came  over  the  head  with  that  click  which  is  so  suggestive  of 


BY   DR   J.   LAMOND   LACK  IE. 


31 


serious  injury  to  the  child.  I  applied  the  forceps  no  less  than 
six  times,  but  I  could  not  get  the  head  to  enter  the  pelvis.  I 
then  tried  to  turn  the  child's  head  round  so  that  the  occiput 
should  be  to  the  front,  and  at  the  same  time  I  endeavoured  to 
turn  the  shoulders  by  external  manipulation;  but  though  I 
could  move  the  head  I  could  not  turn  the  shoulders,  and 
before  I  could  get  the  forceps  applied  the  head  was  back  to  its 
original  position.  Finally,  I  introduced  my  hand  past  the  head, 
and  with  two  fingers  on  the  right  shoulder  and  my  left  hand 
acting  through  the  abdominal  wall,  with  great  ease  I  turned  the 
child  round  till  it  occupied  the  L.O.A.  position.  Once  more 
I  applied  the  forceps,  and  with  comparatively  little  traction 
the  child  was  born  within  three  minutes.  It  weighed  10 J  lbs., 
but  seemed  to  have  suffered  no  injury  except  facial  paralysis, 
which  passed  off  in  three  days.  The  mother  had  a  normal 
puerperium.  She  was  a  woman  of  medium  height,  and  had 
no  pelvic  deformity.  I  delivered  her  of  her  first  child  exactly 
four  years  previously,  when  the  labour  was  almost  normal, 
forceps  being  applied  only  to  bring  the  head  over  the  perinaeum. 


Case  III. — I  hoped  I  had  done  with  difficult  E.O.P.  cases 
for  the  month,  but  I  was  mistaken.  On  Tuesday,  30th  October, 
at  10  a.m.,  I  was  called  to  Mrs  B.,  iii.-para,  who  had  been  in 
labour  since  4  a.m.  The  os  was  the  size  of  half  a  crown.  At 
3  p.m.  the  liquor  amnii  began  to  trickle  away.  At  5  p.m.  the 
os  was  nearly,  but  not  fully,  dilated ;  the  position  was  E.O.P. , 
and  the  head  was  high  up  and  movable  at  the  brim.  At  9  p.m. 
there  was  no  change,  and  inertia  uteri  had  set  in.  The  patient 
was  chloroformed,  and  first  of  all  I  applied  forceps,  but  the 
locking  was  so  unsatisfactory  that  I  was  not  surprised  that 
traction  proved  useless,  and  I  therefore  soon  desisted.  Eemem- 
bering  my  experience  of  two  days  before  (Case  II.),  I  determined 
to  try  internal  rotation  of  the  head.  I  removed  the  forceps, 
then  pushed  the  head  upwards,  and  by  internal  and  external 


32     MANAGEMENT   OF  DIFFICULT   OCCIPITO-POSTEFJOR   CASES, 

manipulation  turned  the  head  round  till  the  vertex  lay  in  the 
RO.A.  position.  A  pain  came  on  and  fixed  it  there,  and  as 
rapidly  as  possible  I  applied  the  forceps.  Extraction  was 
quite  easy,  and  a  living  child  was  born,  9  lbs.  in  weight,  with 
no  signs  of  damage  at  all.  The  interesting  point  about  this 
case  was  that  the  patient  had  been  confined  twice  before,  nine 
years  ago  and  seven  years  ago,  and  on  both  occasions  she  was 
very  ill,  instruments  were  used,  and  both  children  were  born 
dead,  having  died,  the  mother  tells  me,  during  birth.  I  cannot 
help  thinking  that  but  for  artificial  internal  rotation  the  result 
would  have  been  just  the  same  on  this  occasion. 

The  first  and  the  second  and  the  third  cases  which  I  have 
narrated  form  a  striking  contrast.  The  first  was  a  primipara 
who  presented  all  the  usual  features  of  a  malposition  of  the 
head — a  slow  first  stage,  premature  rupture  of  the  membranes, 
and  oedema  of  the  anterior  segment  of  the  cervix,  which  one 
notes  seems  in  these  cases  always  to  hang  free  in  the  pelvis 
between  the  head  and  the  outlet.  The  second  stage  was 
delayed,  the  descent  of  the  head  was  only  partial,  spontaneous 
rotation  did  not  occur,  the  forceps  slipped  several  times,  but 
ultimately  the  patient  was  delivered  simply  by  excessive 
forceps  traction.  Had  forceps  failed,  one  had  to  think  of 
craniotomy,  symphysiotomy,  or  pubiotomy.  The  second  and 
third  cases  presented  the  same  preliminary  feature  as  Case  I., 
but  the  head  was  still  movable  at  the  brim.  There  were  several 
possibilities  of  treatment  had  forceps  ultimately  failed — 
Cesarean  section,  embryulcia,  etc. — but  the  whole  object  of 
this  paper  is  to  emphasise  the  fact  that  to  rectify  a  malposition, 
if  diagnosed  early,  is  possible  and  sometimes  easy.  I  have 
rarely  been  so  struck  with  the  effects  of  treatment  as  in  the 
second  case,  where  what  proved  almost  an  intractable  case 
became  quite  suddenly,  by  simply  rotating  the  child,  one  of 
the  easiest  high  forceps  cases  I  have  ever   experienced.     The 


BY   DR   J.    LAMOND   LACKIE.  33 

child  was  large,  it  was  post-mature,  but  once  it  was  placed 
in  a  normal  position  it  was  delivered  in  a  very  few  minutes. 
Before  resorting  to  a  more  serious  obstetric  operation,  such  as 
craniotomy,  I  should  certainly  have  performed  internal  version, 
which  is  generally  recommended  in  these  cases,  but  the  chances 
for  the  child  would  then  have  been  much  diminished.  Every- 
thing was  no  doubt  favourable  for  artificial  rotation  :  the  head 
was  still  not  properly  engaged,  the  liquor  amnii  had  not  all 
escaped,  and  the  patients  were  multiparas.  Since  in  nine  cases 
out  of  ten  an  E.O.P.  rotates  so  that  the  occiput  comes  forward, 
one  would  not  attempt  this  operation  if  the  head  were  descend- 
ing with  the  pains ;  one  would  simply  further  rotation  chiefly 
by  increasing  flexion.  In  all  text-books  reference  is  made  to 
artificial  rotation  of  the  head  when  it  has  reached  the  pelvic 
floor,  and  this  is  common  practice ;  but  only  in  a  few,  and  these 
are  foreign,  is  rotation  when  the  head  is  high  up  recommended 
as  a  possible  method  of  treatment.  I  am  not  sure  that  in  this 
country  the  value  of  artificial  rotation  of  the  whole  child  when 
the  head  refuses  to  enter  the  pelvis  has  been  duly  appreciated. 
Under  the  circumstances  which  prevailed  in  Cases  II.  and  III., 
I  should  be  inclined,  if  an  E.O.P.  were  diagnosed  early,  to  again 
try  artificial  rotation,  rather  than  risk  a  very  difficult  forceps 
case — a  possible  sacrifice  of  the  child  by  version,  or  a  certain  one 
by  embryotomy. 


Br  Barbour  was  much  interested  in  Dr  Lackie's  communica- 
tion, which  drew  attention  to  a  method  of  dealing  with  occipito- 
posterior  cases  which  was  not  sufficiently  recognised  in  this 
country.  It  was  noteworthy  that  the  head  was  delivered  with 
much  greater  ease,  lying  in  the  same  diameter,  with  the  occiput 
to  the  front  instead  of  to  the  back,  because  the  difficulty  was 
evidently  in  this  case  not  in  the  longer  rotation  the  head  had 
to  undergo,  but  in  some  cause  interfering  with  its  engagement, 

C 


34      MANAGEMENT   OF   DIFFICULT   OCCIPITO-POSTERIOR   CASES, 

or  with  proper  flexion.  The  cause  of  deficient  flexion  in 
occipito-posterior  positions  was  not  evident.  It  had  been 
ascribed  to  the  promontory,  but  this  explanation  was  not 
adequate.  He  congratulated  Dr  Lackie  on  his  successful 
management  of  these  cases. 

Dr  Haig  Ferguson  cordially  thanked  Dr  Lackie  for  his 
interesting  and  suggestive  paper.  All  present,  no  doubt,  had 
had  experiences  such  as  Dr  Lackie's  in  the  slipping  of  forceps 
in  occipito-posterior  cases.  In  his  opinion,  this  slipping  was 
due  to  the  head  being  extended  and  the  forceps  grip  being  too 
near  the  sinciput  and  not  sufficiently  far  back  on  the  head. 
This  could  be  rectified  by  promoting  flexion  of  the  head  by 
manual  manipulation,  after  which  the  forceps  can  generally  be 
applied  satisfactorily  without  fear  of  slipping.  When  the 
forceps  is  applied  when  the  head  is  extended,  traction  simply 
tends  to  keep  up,  if  not  to  increase,  the  extension,  and  so  the 
delivery  of  the  head  is  not  by  any  means  facilitated  even  when 
the  blades  do  not  slip  off  the  head.  He  was  much  interested 
to  hear  that  by  an  apparently  comparatively  simple  manoeuvre, 
as  Dr  Lackie  described  it,  a  right  occipito-posterior  position, 
as  in  Case  II ,  was  converted  even  into  an  L.O.A.  He  would 
certainly  try  this  method  of  artificial  rotation  the  next 
suitable  opportunity  he  had,  as  it  seemed  not  only  rational,  but 
eminently  calculated  to  conserve  fcetal  life,  a  point  so  strongly 
and  rightly  insisted  on  by  the  President  in  his  address  just 
delivered. 

Dr  James  Ritchie  felt  indebted  to  Dr  Lackie  for  having 
reported  cases  showing  the  ease  with  which  in  posterior 
positions,  under  suitable  conditions,  the  body  of  the  child  could  be 
rotated.  Kotation  of  the  head  alone  was  not  satisfactory.  He 
thought  that  the  chief  reason  why  delivery  was  more  difficult 
in  posterior  than  in  anterior  positions  lay  in  the  fact  that, 
in  consequence  of  the  projection  of  the  promontory  there  is  less 
room  at  the  posterior  end  of  the  oblique  diameter  than  in  front, 


BY    DR   J.    LAMOND   LACKIE. 


35 


and  that  the  sinciput,  being  smaller,  passes  more   easily  than 
the  occiput. 

Br  Dewar  thanked  Dr  Lackie  for  his  eminently  practical 
paper.  Papers  such  as  the  one  read  were  a  great  help  to  the 
practitioner  in  his  everyday  life,  inasmuch  as  they  refreshed 
the  memory  by  recalling  some  of  the  principles  in  the  treat- 
ment of  difficult  cases,  which  are  apt  from  infrequent  application 
to  become  dim  in  the  mind.  In  thinking  over  those  occipito- 
posterior  positions,  one  or  two  thoughts  had  occurred  to  him. 
A  medical  man  was  sometimes  called  to  a  labour  case  at  a  very 
early  stage.  It  was  very  customary  for  him,  after  making  the 
usual  vaginal  examination  and  finding  the  os  undilated  or  only 
very  slightly  dilated  and  the  passage  dry,  to  heave  a  sigh,  perhaps, 
if  it  should  be  three  o'clock  in  the  morning,  and  tell  the  patient 
and  her  friends  that,  as  labour  was  hardly  commenced,  he 
would  go  home,  and  come  back  in  the  morning.  He  confessed 
that  he  used  to  follow  such  a  practice,  but  experience  had 
taught  him  to  adopt  a  different  method,  which  he  had  now 
practised  for  many  years.  By  being  content  with  a  simple 
vaginal  examination  the  medical  man  missed  his  best  opportunity 
of  rectifying  an  abnormal  position  if  it  should  be  present.  His 
routine  practice  was,  if  the  os  was  undilated,  to  make  an  abdominal 
palpation,  as  he  was  anxious  to  find  out,  if  possible,  what  presenta- 
tion and  what  position  he  had  to  deal  with.  It  was  easy  to  read 
in  the  text-books  what  to  do  in  difficult  cases,  but  it  was  not  so 
easy  in  practice ;  yet,  with  patience  and  a  little  care,  if  such  an 
opportunity  occurred,  it  was  fairly  easy,  by  palpation,  to  make  out 
whether  the  presentation  was  a  transverse,  a  breech,  or  an 
occipital  one.  If  occipital,  he  should  try  to  satisfy  himself 
whether  the  position  was  occipito-anterior  or  occipito-posterior ; 
if  the  latter,  he  should  then  endeavour  to  rectify  at  once,  as  it  is 
very  much  easier  to  rotate  the  child  at  that  stage,  when  the 
membranes  were  still  intact,  than  at  a  later  stage,  when  the  head 
was  engaged  in  the  brim  or  in  the  pelvic  cavity.     If,  however, 


36      MANAGEMENT   OF   DIFFICULT   OCCIPITO-POSTERIOR   CASES, 

the  case  was  not  seen  till  at  a  later  stage,  he  favoured  internal 
rotation  by  the  hand  rather  than  by  the  forceps,  as  being  less 
dangerous  to  both  mother  and  child.  He  narrated  the  difficulties 
of  an  occipito-posterior  case,  in  which  the  persistence  of  the 
position  was  probably  due  to  the  tip  of  the  coccyx  projecting 
forwards  at  a  right  angle  to  the  sacrum,  and  thus  diminishing 
the  antero-posterior  diameter  of  the  pelvic  outlet  to  something 
like  3|  inches,  which  was  certainly  too  little  to  allow  the  passage 
of  the  occipito-frontal  diameter  of  the  head,  which  would  be 
at  least  not  less  than  4J  inches.  The  position  remained  a 
persistent  posterior  one,  in  spite  of  all  his  endeavours  to  rectify 
it,  and  while  attempting  to  deliver  with  forceps,  a  snap  was 
heard,  after  which  the  head  was  extracted  in  the  ordinary  way 
of  K.O.P.'s.  The  coccyx  was  fractured.  In  the  patient's 
second  labour  the  same  difficulty  occurred,  the  coccyx  having 
united  at  a  similar  angle.  On  this  occasion,  profiting  by  the 
experience  of  the  previous  labour,  he  forcibly  fractured  the 
coccyx  with  his  fingers,  so  as  to  avoid  damage  to  the  occiput, 
which  was  present  in  the  first  labour,  and  delivery  was  com- 
paratively easy.  On  the  third  occasion,  with  the  tip  of  the 
coccyx  in  the  natural  position,  the  position  was  an  R.O.P.  again, 
which  very  soon  rotated  into  an  anterior  position,  and  the 
child  was  born  without  assistance,  showing  that  the  peculiar 
position  of  the  coccyx  in  the  first  two  labours  was  the  cause  of 
the  failure  of  rotation.  With  regard  to  the  question  raised  by 
Dr  Barbour,  as  to  why  the  head,  when  rotated  from  the  posterior 
to  the  anterior  position,  should  engage  in  the  brim  more  easily, 
Dr  Dewar  thought  that  an  answer  would  be  found  in  the  fact 
that  after  rotation  above  the  brim,  the  belly  of  the  child  would 
adapt  itself  to  the  concavity  of  the  uterus  and  pelvis  behind, 
the  spinal  column  would  curve  correspondingly,  and  the  occipito- 
spinal  joint  coming  behind  the  line  of  the  uterine  force,  flexion 
would  take  place,  allowing  the  head  to  pass  easily  through  the 
pelvic  inlet  in  the  wide  oblique  diameter. 


BY  DR  J.    LAMOND   LACKIE.  37 

Br  Church  joined  in  the  expression  of  indebtedness  to  Dr 
Lackie  for  his  practical  and  suggestive  paper.  He  referred  to 
the  danger  of  injury  to  the  maternal  parts  over  and  about  the 
region  of  the  ischial  spine  from  pressure  of  the  child's  head 
in  occipito-posterior  positions.  Sloughing  and  septic  troubles 
might  supervene  from  such  injury.  He  had  read  Professor  Sir 
Halliday  Croom's  paper  on  this  subject,  and  had  been  impressed 
with  the  importance  of  this  point.  He  had  met  with  an 
illustrative  case  in  his  own  practice.  He  expressed  the  opinion 
that  in  all  great  lying-in  institutions  a  detailed  account  of 
every  presentation  should  be  recorded  in  the  case  books.  This 
would  add  to  their  scientific  value.  For  example,  "Vertex" 
was  not  enough.  The  particular  vertex  presentation  should  be 
defined,  and  so  on.  In  connection  with  occipito-posterior 
positions,  it  would  appear  (from  the  Talmud)  that  the 
ancient  Jews  were  of  opinion  that  most  female  children  were 
born  in  this  position.  Hence  a  medical  reason  for  the  longer 
puerperium  of  the  mother  and  the  longer  Levitical  period  of 
ceremonial  uncleanness.  By  kind  permission,  he  had  looked 
at  the  books  of  our  own  Maternity  Hospital  and  found  that 
there  were  considerably  more  female  than  male  occipito-posterior 
positions.  Obstetricians  of  to-day  could  generalise  like  the 
Eabbis  of  old,  but,  like  them,  they  still  found  in  occipito-posterior 
positions  possible  conditions  of  danger  and  difficulty.  Dr  Lackie 
had  shown  us  how  to  lessen  the  difficulty. 

Br  Oliphant  Nicholson  thanked  Dr  Lackie  for  his  interesting 
paper,  and  wished  to  make  a  few  remarks  regarding  the 
management  of  difficult  occipito-posterior  labour.  He  had  had 
quite  an  abnormal  number  of  such  cases  recently  in  his  dis- 
pensary practice,  and  these  positions  of  the  head  seemed  to  be 
commoner  than  was  generally  supposed.  Occipito-posterior 
labour  might  be  easy  or  difficult ;  if  it  was  really  difficult,  it 
constituted  one  of  the  most  undesirable  and  dangerous  complica- 
tions due  to  malposition  of  the  foetus — a  presenting  shoulder 


38      MANAGEMENT   OF   DIFFICULT   OCCIPITO-POSTERIOR   CASES, 

was  infinitely  more  easy  to  deal  with  successfully.  There  were 
several  methods  of  management,  in  these  cases,  and  he  had 
tried  them  all.  He  thought  everyone  who  had  had  a  large 
experience  in  this  kind  of  case,  would  agree  that  the  manual 
rotation  of  the  child's  head  and  body  into  the  correct  position 
was  the  best.  It  was  the  most  scientific  treatment,  and  it  was 
also  the  best  for  the  safety  of  mother  and  child.  He  would 
like  to  mention  some  of  the  methods  commonly  adopted,  and 
briefly  discuss  their  application  to  certain  cases.  1.  First,  there 
was  delivery  by  the  forceps  without  any  attempt  to  correct  the 
position  of  the  head.  This  was  probably  the  commonest 
method  of  all,  because  the  general  practitioner  did  not  always 
trouble  to  diagnose  the  position  of  the  head.  If  a  labour  was 
lingering,  and  the  head  did  not  descend,  forceps  were  applied, 
and  the  doctor  pulled — often  with  his  utmost  strength — till  the 
child's  head  appeared  at  the  vulva.  Most  of  these  cases  were 
persistent  occipito-posterior  ones.  Sometimes  rotation  of  the 
child's  head  occurred  during  traction,  especially  when  axis- 
traction  forceps  were  used,  but  generally  the  occiput  emerged 
behind.  Now,  even  when  one  knew  that  the  position  of  the 
head  was  occipito-posterior,  this  method  was  sometimes  good 
practice.  Eobert  Barnes  had  advised  it,  and  when  the  head  was 
relatively  small,  and  one  had  not  to  exert  dangerous  traction, 
the  delivery  was  generally  safely  completed  without  extensive 
perineal  laceration.  2.  A  slight  modification  of  this  method  was 
gradual  rotation  of  the  head  carried  out  by  the  forceps  during 
traction.  The  blades  were  removed  and  re-applied  several  times 
till  rotation  was  completed.  This  method  was  applicable  to 
those  cases  where  the  head  showed  indications  of  rotating 
during  traction;  the  application  of  the  blades  two  or  three 
times  was  the  important  thing  to  complete  rotation.  3.  The 
next  method  was  the  manual  rotation  of  the  head  alone  to 
carry  the  occiput  behind  the  pubic  arch.  It  was  then  held 
in  its  new  position  and  forceps  applied.     In  applying  this  treat- 


BY  DR   J.   LAMOND   LACKIE.  39 

ment  it  was  necessary  to  know  that  the  case  was  an  occipito- 
posterior  one,  and  he  had  to  confess — after  fifteen  years' 
experience — that  he  could  never  be  certain  of  this  point  by 
means  of  fontanelles  and  sutures.  In  every  case  where  the 
head  remained  high  up  and  would  not  descend,  he  made  a  very 
thorough  vaginal  examination.  With  the  patient  well  over  on 
her  left  side  and  under  chloroform,  the  whole  of  the  left  hand 
was  passed  into  the  vagina  and  the  fingers  pushed  over  the 
head  until  an  ear  was  felt.  In  occipito-posterior  cases  an  ear 
was  always  easily  reached;  that  point  by  itself  was  rather 
suggestive  of  the  position.  But  this  method  he  had  found 
excellent,  inasmuch  as  it  not  only  verified  the  position,  but 
indicated  the  direction  in  which  one  should  rotate.  One  always 
rotated  away  from  the  ear.  This  method  of  correcting  the 
position  of  the  head  by  means  of  the  hand  was,  as  a  rule,  very 
easily  carried  out.  He  always  used  the  left  hand,  and  the 
head,  being  firmly  grasped,  was  lifted  up  right  out  of  the  pelvis 
between  the  pains.  The  manoeuvre  was  often  carried  out  with 
extraordinary  ease;  sometimes,  however,  it  was  very  difficult, 
and  then  one  must  adopt  some  other  means  of  effecting  delivery. 
The  main  objection  to  this  method  was  that,  unless  the  body  of 
the  child  was  rotated  at  the  same  time,  the  head  had  a  great 
tendency  to  spring  back  to  its  old  position.  Thus  it  was 
always  necessary,  after  rotating  the  head  in  this  way,  to  keep 
one's  hand  on  it,  and  apply  the  forceps  with  the  other  hand. 
He  wished  to  mention  the  advantage,  in  such  cases,  of  introduc- 
ing the  upper  blade  first ;  after  the  application  of  this  blade,  the 
head  could  be  kept  in  position  while  the  lower  blade  was 
introduced.  He  might  mention  also  the  advantage  of  the 
axis-traction  forceps  with  straight  blades — such  as  Milne- 
Murray's — for  these  cases,  because  with  them  a  better  grip  of 
the  head  over  the  parietal  bones  was  obtained;  the  ordinary 
curved  blades  were  certainly  more  apt  to  slip  off  the  head 
during  traction.     When  the  forceps  were  got  on  to  the  head  in 


40      MANAGEMENT   OF  DIFFICULT   OCCIPITO-POSTERIOR   CASES, 

its  new  position  and  traction  was  made,  the  body  of  the  child 
swung  round ;  the  neck  of  the  child  did  not  break.  4.  The 
best  method  of  all  was  manual  rotation  of  both  the  head  and 
the  body  of  the  child.  The  body  was  rotated  through  the 
abdominal  wall  by  placing  the  right  hand  behind  the  shoulder 
and  pressing  it  forwards,  this  being  done  at  the  same  time  as 
the  left  hand  in  the  vagina  rotated  the  head.  In  some  cases 
this  was  easily  done,  but  in  others  very  great  difficulty  was 
experienced  in  getting  the  body  of  the  child  round.  Most 
practitioners  had  met  with  these  troublesome  cases,  and  the 
natural  thing  was  to  pass  the  hand  still  further  into  the  uterus, 
in  order,  if  possible,  to  get  the  body  to  rotate.  Last  year,  in  an 
exceptionally  difficult  case  of  this  kind,  Dr  Nicholson,  in  passing 
the  hand  higher  up,  came  upon  the  child's  shoulder,  and  grasped 
it  within  the  uterus.  Then  rotation  was  accomplished  with 
surprising  ease.  He  was  much  impressed  at  the  time  with 
this  method,  and  he  had  no  doubt  that  others  who  had  dis- 
covered the  manoeuvre  had  been  similarly  impressed.  On 
looking  up  the  literature  of  the  subject,  he  found  that  it  had 
been  described,  and  advocated  to  the  exclusion  of  all  other 
methods,  by  Professor  Mcllwraith  of  Toronto,  in  a  paper 
published  in  the  Canadian  Practitioner  and  Review  of  February 
1905.  He  did  not  know  whether  others  had  described  the 
manoeuvre ;  but  it  was  certainly  one  that  deserved  to  be  more 
widely  known,  and  Dr  Lackie  had  brought  the  matter  pro- 
minently before  them  in  his  excellent  paper. 

Dr  Lackie,  in  reply,  said  that  it  was  to  him  quite  remarkable 
how  easy  the  children  were  delivered  after  artificial  internal 
rotation  at  the  brim.  In  the  first  case  he  had  converted  an 
E.O.P.  into  an  L.O.A. ;  in  the  second  he  managed  to  rotate  the 
head  only  to  the  E.O.A.  position,  which,  however,  was  quite 
sufficient.  When  it  was  possible,  rotation  of  the  whole  child 
was  preferable  to  mere  rotation  of  the  head.  He  thanked  the 
Society  for  the  kind  way  in  which  they  had  received  his  paper. 


« 


?i^»  j> .  . 


[Tnset  at  page  41. 


EXHIBITION   OF   SPECIMENS.  41 

Meeting  II.— December  12,  1906. 
Dr  N.  T.  Brewis,   Vice-President,  in  the  Chair. 

I.  The  following  gentlemen  were  elected  Ordinary  Fellows 
of  the  Society :— D.  Lloyd  Koberts,  M.D.,  F.K.C.P.,  11  St  John 
Street,  Manchester;  J.  S.  Edwards,  M.B.,  Ch.B.,  University 
Union,  Edinburgh. 

II.  Dr  Brewis  showed— (a)  Two  examples  of  endothel- 
ioma of  the  ovary,  removed  from  a  patient  aged  20.  Miss 
McK.,  admitted  September  1906;  complaining  of  swelling 
in  the  lower  abdomen  and  pain  in  that  region  when  she  turned 
herself;  duration  two  months.  She  had  always  had  pain  at 
her  periods,  but  since  January  1906  that  pain  had  been  more 
severe.  She  had  strained  herself  at  that  time  by  lifting  a 
very  heavy  weight.  Two  months  ago,  when  an  attack  of  pain 
had  come  on  after  turning  herself  in  bed,  she  felt  a  hard  lump 
the  size  of  a  marble  on  the  right  side  of  her  lower  abdomen. 
This  grew  gradually  larger.  A  short  time  after  she  had 
noticed  the  first  swelling,  she  felt  another  on  the  left  side  of 
the  lower  abdomen.  This  also  gradually  increased  in  size, 
but  she  thought  it  was  softer  to  the  feel  than  that  on  the 
right  side.  On  admission,  an  irregular  mass  was  filling  the 
hypogastric  and  lower  part  of  the  umbilical  region.  Menstrua- 
tion regular,  twenty-eight-day  type;  duration,  seven  days; 
quantity  fairly  copious ;  pain  present.  Operation. — Abdominal 
section,  double  ovariotomy;  small  quantity  of  free  fluid  in 
abdomen.  Pathological  Report. — Extracts  from  Mr  Muirs 
letter : — "  The  condition  is  that  of  lymphatic  endothelioma,  but  is 
undergoing  extensive  colloid  degeneration.  The  sections  from 
different  parts  of  both  the  right  and  left  ovaries  show  that  the 
structure  is  much  the  same  in  all.  The  essential  tissue 
element  is  seen  to  be  made  up  of  endothelial  cells  arranged 
in  a  very  indefinite  manner,  but  in  parts  one  can  make  out 


42  EXHIBITION   OF   SPECIMENS. 

these  cells  to  be  lining  lymphatic  spaces,  and  some  spaces 
are  filled  with  cells  forming  an  alveolar-like  structure.  The 
stroma  in  parts  is  well  denned  and  at  others  scanty.  The 
areas  showing  an  open  network  of  delicate  stroma  forming 
spaces,  are  really  the  tumour  cells  undergoing  colloid  degenera- 
tion ;  in  parts  their  condition  is  more  advanced,  showing 
complete  transformation  of  the  endothelial  cells  into  colloid 
material;  only  the  stroma  persists."  Patient  went  home 
feeling  quite  well,  on  the  thirty-second  day  after  operation, 
having  made  a  splendid  recovery,  only  interrupted  by  a  fainting 
turn  on  the  eighteenth  day  after  operation. 

(b)  Bare  variety  of  dermoid  tumour,  tuberculous  tubes, 

AND   INTRALIGAMENTARY  TUMOUR   OF  THE  OTHER   OVARY.        Miss 

B.,  set.  24,  admitted  8th  October  1906,  complaining  of  pain 
in  the  right  side,  distension  of  the  abdomen,  and  occasional 
pain  in  the  left  side.  Duration  of  illness,  four  years ;  symptoms 
more  marked  during  the  last  year.  Menstruation  regular, 
twenty -eight-day  type ;  duration,  two  to  three  days ;  flow  less 
in  quantity  since  onset  of  pain  in  the  right  side  a  year  ago. 
On  opening  the  abdomen  a  large  grey- walled  cyst  was  exposed, 
and  through  parts  of  the  wall  of  the  cyst  small  yellow  bodies 
like  coriander  seeds  could  be  seen  floating  about  in  the  interior 
of  the  cyst.  The  cyst  was  tapped,  clear,  straw-coloured  fluid 
and  little  yellow  bodies  escaping;  the  cyst  was  then  removed 
without  any  special  difficulty.  In  the  situation  of  the  right 
ovary  was  a  body,  yellowish  in  colour,  and  in  shape  and  size 
like  a  medium-sized  horse-chestnut.  This  was  adherent  to  the 
omentum,  and  had  to  be  dissected  from  dense  adhesions  to  the 
lower  end  of  the  caecum.  The  fimbriated  extremity  of  the 
right  tube  was  attached  to  this  body,  and  was  swollen. 
The  left  tube  was  distended  in  its  outer  third  to  the  size  of  a 
pigeon's  egg.  A  round  yellow  body  the  size  of  a  pea  was 
attached  to  the  fimbriated  extremity.  The  left  ovary  was 
hard  and  cirrhotic  looking.     Under  the  left  ovary  and  parietal 


EXHIBITION   OF  SPECIMENS.  43 

peritoneum,  covering  the  left  wall  of  the  pelvis,  was  a  cyst 
firmly  adherent  to  the  wall  of  the  pelvis.  The  patient,  although 
very  sick  and  much  pained  for  some  days  after  the  operation, 
was  making  an  uninterrupted  recovery. 

(c)  Dermoid  tumour  of  the  ovary,  which  ruptured  during 
administration  of  the  anaesthetic : — Miss  R,  age  28,  admitted 
2nd  November  1906.     Complaint. — Distension  of  the  abdomen ; 
duration,  a   fortnight.     Some  little   pain  in  September  1906 ; 
frequency  of  micturition  at  the  end  of  October,  with  a  little 
fulness  of  the  lower  part  of  the  abdomen.     During  the  next 
ten   days   the  abdomen  gradually   became   distended,   till   on 
the  day  of  operation  it  had  reached  the  size  of  a  six  months' 
pregnancy.      While   the   anaesthetic   was   being  administered, 
the   swelling  disappeared,  the   abdomen   becoming  quite   flat. 
On   opening   the   abdomen,   greasy  fluid,  fat,  and  hair  welled 
up  into  the  wound.     A  dermoid  cyst  about  the  size  of  a  foetal 
head  was  found,  with  a  rupture  in  the  cyst  wall  about  2  inches 
long.     This   cyst,  a   dermoid  of   the  left  ovary,  was  removed. 
The    right    ovary    was    slightly   enlarged,   and    cystic.      The 
abdomen  was  thoroughly  washed  out,  but  great  difficulty  was 
experienced   in   getting   rid   of   all  the  fatty  material.     After 
the  operation  the  pulse  kept  very  fast — over  100 — and  twenty- 
four    hours    after    the    operation   the   patient    became    very 
restless.     On  the  morning  of  the  second  day  she  was  slightly 
delirious.     The   same  day   a   condition   of    stupor   developed. 
This   gradually   deepened;   her   pulse   remained   between    100 
and  130 ;  her  respirations  were  at  times  deep,  with  long  pauses 
between,  but  never  stertorous,  and  she  died  on  the  third  day 
after   the   operation.     The   wound   was  opened  on  the  day  of 
her  death,  and  there  was  no  sign  of  peritonitis.     The  tempera- 
ture the  day  after  the  operation  was  99°  F. ;  the  day  before  her 
death  it  was  subnormal,  and  remained  so  till  just  before   her 
death,  when  it  rose  to  102°  F. 

(d)  Euptured    ovarian  tumour,   presenting    microscopic 


44  EXHIBITION   OF   SPECIMENS. 

characters  of  adenocarcinoma  and  tubercle : — Mrs  A.,  age  53 ; 
admitted  22nd  October  1906;  married  twenty-eight  years; 
widow  twelve  years;  six  children.  Complaint — Swelling  on 
the  right  side  of  the  abdomen,  with  a  continuous  sore 
feeling  in  that  region.  Patient  had  reached  the  menopause 
two  years  before.  Between  that  time  and  six  months  ago, 
she  noticed  that  a  swelling  was  present  on  the  right  side 
of  the  abdomen.  This  part  then  became  tender,  and  had 
remained  so  since.  Six  months  ago  a  red  discharge  like 
that  at  her  periods  set  in,  and  lasted  six  weeks.  Since  then 
this  discharge  had  returned  at  irregular  intervals,  being 
usually  very  copious,  and  sometimes  had  an  unpleasant  odour. 
It  was  sometimes  clotted.  She  had  had  pain  in  the  right  side, 
and  an  uncomfortable  bursting  sensation  for  the  past  six 
months.  Her  husband  and  one  child  died  of  consumption. 
A  large  firm  mass  filled  the  left  iliac,  left  lumbar,  lower  part 
of  umbilical,  and  left  side  of  hypogastric  regions.  A  dull  note 
in  the  flanks  changed  from  side  to  side  with  the  altered 
position  of  the  patient.  Operation. — On  opening  the  abdomen 
a  large  quantity  of  free  fluid  escaped.  The  omentum  was 
found  adherent  to  the  tumour.  The  intestines  were  roughened, 
red,  and  extensively  studded  with  tubercles  Ovariotomy 
was  performed.  There  was  considerable  bleeding  and  oozing. 
Everything  in  the  pelvis  was  very  friable,  and  bled  easily. 
The  left  ovary  was  a  normal  senile  one,  and  was  not  removed. 
Pathological  Report. — The  tumour  had  the  appearance  of  a 
columnar -celled  carcinoma.  The  specimen  also  consisted  in 
parts  of  granulation  tissue  infiltrated  with  leucocytes,  and 
presenting  advanced  necrosis,  so  that  its  features  suggested 
the  probability  of  tuberculosis.  Patient  got  up  on  the  twenty- 
first  day  after  operation,  having  made  an  uninterrupted  recovery, 
and  went  home  a  week  later,  feeling  and  looking  quite  well. 

(e)  Uteeus  with  large  cervical  fibroid,  removed  at  the 
fifth  month  of  pregnancy.     The  abdomen  was  opened,  and  the 


EXHIBITION   OF   SPECIMENS. 


45 


foetus,  which  was  not  viable,  was  delivered  by  Csesarean  section ; 
then  the  uterus  and  large  cervical  fibroid  which  filled  the  pelvis 
were  removed  by  hysterectomy.  (Described  in  paper,  page  49). 
(f)  Uterus  with  fibroid  tumour  in  lower  uterine 
segment,  removed  at  term  by  supravaginal  hysterectomy  after 
Ccesarean  section.  Mrs  B.,  age  33.  Married  ten  months;  no 
children ;  no  miscarriages.  History. — Patient  was  confined  to 
bed  from  Easter  Monday  1906  until  May  1906  with  severe 
sickness.  When  she  got  up  she  was  seized  by  a  violent  pain 
in  her  left  side,  chiefly  in  the  left  iliac  region.  Pregnancy, 
complicated  by  a  fibroid  tumour,  was  diagnosed.  She  was  kept 
in  bed  for  seventeen  weeks  on  account  of  the  pain.  A  belt  was 
then  given  her  to  wear.  She  got  up,  and  had  no  recurrence  of 
the  pain.  The  pregnancy  was  allowed  to  go  on  till  full  time. 
When  labour  set  in,  the  foetal  head  was  found  occupying  the 
right  side  of  the  pelvis  and  a  hard  rounded  swelling  the  left 
side  of  the  pelvis,  both  situated  just  above  the  brim.  The 
abdomen  was  opened,  and  the  rounded  swelling  was  seen  to  be 
a  rounded  mass  the  size  of  a  cricket  ball,  in  the  wall  of  the 
uterus,  at  the  left  side  of  the  lower  uterine  segment  and  under 
the  bladder.  The  child  was  delivered  alive  by  Caesarean 
section.  The  placenta  was  removed,  and  the  uterus,  which  had 
another  projection  from  the  wall  at  the  fundus,  was  removed 
by  supravaginal  hysterectomy.  On  section,  the  rounded  mass 
was  seen  to  be  a  fibroid  tumour,  and  the  cylindrical  projection 
near  the  fundus  a  fibroid  growth  which  had  undergone  colloid 
degeneration.  Both  mother  and  child  did  very  well,  the  mother 
making  a  rapid  recovery.     (Described  in  paper,  page  49). 


III.  Br  Haig  Ferguson  showed — (a)  1.  Tubal  pregnancy 
(two  months),  showing  dilated  ostium  tubse,  and  ovum  partially 
protruding.  Eupture  had  at  the  same  time  occurred  slightly 
into  the  broad  ligament.  Free  blood  in  abdominal  cavity; 
operation    on    account   of    pain,   haemorrhage,   and   continued 


46  EXHIBITION   OF   SPECIMENS. 

orowth  of  tumour.  2.  Complete  tubal  abortion  (about  second 
month).  Tube  apparently  empty,  but  still  bleeding  through 
open  ostium.  Pelvis  full  of  clot,  containing  shreds  of  membrane 
of  gestation  sac.  Operation  for  pain,  steadily  increasing 
hematocele,  and  symptoms  of  internal  bleeding.  In  this  case 
it  was  necessary  to  drain  through  the  posterior  fornix  into  the 
vagina,  on  account  of  the  large  raw  surface  behind  the  uterus, 
which  was  packed  with  gauze.  Both  patients  made  good 
recoveries. 

(b)  Large  double  pyosalpinx,  apparently  tubercular.  The 
uterus  was  removed  at  the  same  time,  to  render  operation 
possible.  Free  ends  of  both  tubes  adherent  to  each  other 
behind  the  uterus. 

(c)  Uterus  with  fundal  cancer,  removed  by  vaginal 
hysterectomy  from  a  nulliparous  patient,  aged  about  55.  She 
complained  of  haemorrhage  as  her  only  symptom,  and  there  was 
no  pain.  Uterus  measured  2 \  inches  with  the  sound.  Curettage ; 
scrapings  reported  as  malignant  adenoma.  Disease  limited  to 
fundus.  Satisfactory  recovery.  Patient  had  weak  heart,  so 
the  vaginal  route  was  chosen,  which,  though  more  difficult  in 
a  nullipara,  caused  less  disturbance  and  shock  to  the  patient. 

(d)  Chorion  epithelioma  of  uterus,  removed  by  vaginal 
hysterectomy.  This  was  the  second  specimen  of  decidnoma 
malignum  shown  here  to  the  Society  by  Dr  Ferguson  this  year. 
The  patient,  Mrs  0.,  age  38,  had  an  imperfect  abortion,  and 
was  sent  to  hospital  for  curettage.  Severe  haemorrhage  oc- 
curred after  curetting ;  scrapings  were  examined  by  pathologist, 
who  reported  chorion-epithelioma.  Uterus  was  removed  by 
vaginal  hysterectomy.  Good  recovery.  Patient  remaining  well 
four  and  a  half  months  after  operation.  The  former  specimen, 
which  he  now  brought  for  comparison,  was  removed  in  April  last, 
and  the  patient  was  still  in  excellent  health.     Her  age  was  47. 

(e)  Inverted  uterus,  of  puerperal  origin,  after  a  carefully 
conducted  labour.     Insidious  commencement,  with   practically 


EXHIBITION   OF   SPECIMENS. 


47 


no  symptoms.  Eecognised  six  weeks  after  labour;  reduction 
impossible;  vaginal  hysterectomy;  good  recovery.  (Case 
reported  in  full  in  Journal  of  Obstetrics  and  Gynaecology  of 
British  Empire,  October  1906.) 

(/ )  Soft  subperitoneal  fibroid,  resembling  an  ovarian  cyst. 
This  tumour  was  removed  by  abdominal  hysterectomy,  from 
a  patient  aged  60.  The  uterus  was  completely  upside  down 
in  the  pelvis,  and  was  normal  in  size  as  measured  by  the 
sound.  She  had  been  treated  by  pessaries  for  a  considerable 
time  with  no  benefit.  The  symptoms  were  constant  bladder 
irritation,  and  pelvic  pressure  symptoms.  When  Dr  Ferguson 
saw  the  patient  he  thought  the  tumour  alongside  the  uterus 
was  an  intraligamentous  cyst  in  close  contact  with  the  right 
side  of  the  uterus.  Even  after  removal  the  examination  of 
the  specimen  gave  that  impression,  so  soft  and  fluctuating  was 
the  mass.  The  patient  made  a  good  recovery  from  the  operation, 
and  her  distressful  symptoms  had  quite  disappeared. 

(g)  Chart  showing  ante-partum  temperature  of  105-8°  F. 
(malarial),  when  child  was  born  alive.  The  patient,  a  primi- 
para,  made  a  good  recovery,  and  the  child  did  well.  Labour 
was  to  have  been  induced  prematurely  on  account  of  a  narrow 
pelvis.  The  high  temperature,  however,  combined  with  the 
quinine,  set  the  labour  going  just  at  the  time  the  induction  was 
to  have  been  done,  so  no  further  interference  was  necessary. 

(h)  Uterus,  removed  by  vaginal  hysterectomy,  one  year 
after  a  double  pyosalpinx  (probably  gonorrheal)  had  been 
removed  by  abdominal  section.  The  uterus  was  removed  for 
persistent,  purulent,  and  offensive  uterine  leucorrhoea  combined 
with  pain,  which  resisted  curetting  and  all  other  minor  treat- 
ment. The  patient  and  her  doctor  both  urged  hysterectomy, 
which,  owing  to  the  shortness  of  the  broad  ligaments  (the  result 
of  the  previous  oophorectomy),  was  a  somewhat  difficult  pro- 
cedure. The  uterus,  when  opened  after  removal,  was  found  to 
be  transformed  into  an  abscess  cavity,  with  rough  and  sloughing 


48  EXHIBITION   OF   SPECIMENS. 

mucous  surface,  and  containing  offensive  pus,  penetrating  down 
to  and  involving  the  muscular  walls.  The  patient's  health  was 
completely  re-established  after  the  vaginal  hysterectomy,  and 
she  described  herself  as  an  absolutely  transformed  woman,  as 
regards  her  sense  of  well-being  and  comfort. 

IV.  Dr  Barbour  Simpson  showed  a  replica  of  the  medal 
presented  to  Professor  Pozzi  last  July  by  his  colleagues,  friends, 
and  former  pupils,  in  recognition  of  his  position  as  President 
of  the  Seventeenth  Surgical  Congress,  Paris,  1904,  and  of  his 
promotion  to  the  grade  of  Commander  of  the  Legion  of  Honour. 
Dr  Simpson  mentioned  that  a  Livre  oVOr  was  also  presented  to 
Dr  Pozzi  at  the  same  time,  containing  twenty-four  original 
contributions  by  his  colleagues,  former  pupils,  and  friends. 

V.  Dr  Haultain  showed  a  specimen  obtained  from  a 
multipara  a  fortnight  ago.  The  history  was  that,  when  the 
students  arrived  at  the  case,  they  were  told  that  the  placenta 
had  already  been  born.  The  child  was  born  shortly  after 
their  arrival,  and  the  placenta  came  away  thereafter  normally. 
On  examination  microscopically,  the  purplish  mass  of  the 
specimen  turned  out  to  be  a  blood  tumour  formed  of  capillaries 
and  large  blood-vessels,  with  practically  no  connective  tissue 
between  the  vessels.  The  whitish  mass  was  composed  of 
necrotic  tissue.  There  was  no  trace  of  foetal  structure  or 
decidual  cells.  The  mass  was  about  the  size  of  a  cocoa-nut,  and 
apparently  was  some  abnormal  product  of  conception  analogous 
to  *  Foetus  Ovideus." 

VI.  Dr  James  Ritchie  showed  a  specimen  OF  an  early 
ovum.  The  last  period  had  taken  place  on  4th  July;  the 
abortion  was  on  31st  August ;  but  from  the  size  of  the  ovum, 
conception  must  have  occurred  only  shortly  before  the  date  of 
the  period  which  was  missed. 


CASES   OF   PREGNANCY   COMPLICATED   BY   FIBROID   TUMOURS.    49 


VII.   TWO    CASES    OF    PREGNANCY    COMPLICATED    BY 
FIBROID  TUMOURS,  TREATED  BY  HYSTERECTOMY. 

By  N.  T.  Bkewis,  M.B.,  F.R.C.P.E.,  F.R.C.S.E.,  Gynaecologist,  Royal 
Infirmary,  Edinburgh. 

Cases  of  pregnancy  complicated  by  fibroid  tumours  for  which 
the  operation  of  hysterectomy  is  indicated  are  of  rare  occurrence. 
I  have  previously  reported  to  the  Society  two  such  cases :  one 
for  fibroids  obstructing  the  pelvis  and  causing  severe  pain,  the 
other  for  a  tumour  of  such  extremely  rapid  growth  that  it  filled 
the  entire  abdomen  in  three  months.  I  now  wish  to  add  to 
this  record  two  further  cases.  In  one  the  tumour  filled  the 
pelvis,  and  caused  such  severe  pressure  symptoms  that  the 
operation  was  a  matter  of  urgency,  and  had  to  be  performed 
during  the  sixth  month.  The  other  was  operated  on  at  full 
term,  chiefly  on  account  of  the  obstruction  which  the  tumour 
offered  to  the  passage,  per  vias  naturales,  of  the  child.  In  over 
1000  major  operations,  I  have  had  to  interfere  seven  times  in 
this  manner  with  fibroids  during  pregnancy ;  ovarian  tumours  I 
have  removed  seven  times  during  pregnancy ;  and  in  cases  of 
malignant  disease  in  the  pregnant  uterus,  I  have  performed 
Cesarean  section  and  hysterectomy  on  three  occasions. 

In  each  of  the  cases  I  now  wish  to  record,  Cesarean  section 
preceded  hysterectomy. 

The  first  case  is  that  of  Mrs  C.,  aged  37,  who  was  admitted 
into  Ward  XXXVI.  in  October  of  this  year,  complaining  of 
great  pain  in  the  lower  part  of  the  abdomen  and  in  the  back. 
The  patient  last  menstruated  in  the  first  week  of  June.  The 
early  symptoms  of  pregnancy  soon  asserted  themselves.  In 
July,  trouble  with  micturition  began — at  first  the  act  was 
painful  and  difficult,  afterwards  there  was  increased  frequency. 
At  this  time  also  severe  pain  in  the  back  set  in,  followed  at  a 
short  interval  by  pain  in  the  abdomen,  which  confined  her  to 

D 


50    CASES   OF  PREGNANCY  COMPLICATED   BY  FIBROID   TUMOURS, 

bed,  and  which  continued  until  relief  was  obtained  by  the 
operation.  Her  menstruation  began  at  16,  was  of  the  twenty- 
eight-day  type,  and  lasted  three  days.  The  amount  was  copious 
during  the  first  day,  and  slight  during  the  remaining  two  days. 
There  was  always  pain  on  the  first  day. 

On  physical  examination  the  breasts  were  found  to  be  large, 
and  colostrum  was  easily  expressed  from  the  nipple.  The 
abdomen  was  enlarged  by  a  swelling  which  reached  to  the 
umbilicus.  On  the  right  side  it  projected  markedly,  and  pre- 
sented the  signs  of  a  pregnant  uterus.  On  the  left  there  was 
felt  a  separate  swelling  of  much  harder  consistence.  Per 
vaginam,  the  finger  felt  this  swelling  passing  down  into  the 
pelvis  and  almost  entirely  filling  the  cavity. 

The  cervix  was  situated  far  forward,  immediately  behind 
and  against  the  symphysis  pubis. 

Pregnancy  plus  a  solid  tumour  was  diagnosed ;  the  patient 
was  anaesthetised,  and  an  attempt  made  to  dislodge  the  tumour 
from  the  pelvis.  This  attempt  failed  however.  "We  were 
anxious  to  withhold  any  further  interference  until  the  child 
became  viable,  but  the  pain  continued  so  severe  and  persistent 
that  it  was  feared  some  degenerative  change  might  be  taking 
place  in  the  tumour;  moreover,  her  general  condition  was 
becoming  each  day  less  favourable,  and  to  add  to  her  misery, 
and  to  our  anxiety,  symptoms  of  intestinal  obstruction  and  also 
of  ureteral  pressure  were  beginning  to  manifest  themselves. 
It  was  therefore  clear  that  we  had  to  consider  what  could 
best  be  done  in  the  mother's  interest.  With  this  object  in  view 
we  determined  to  open  the  abdomen,  deliver  the  child  by 
Cesarean  section,  and  then  proceed  to  remove  the  tumour. 

A  mesial  incision  was  made  from  the  pubis  to  above  the 
umbilicus.  On  opening  into  the  abdominal  cavity  the  gravid 
uterus  at  once  presented,  and  was,  after  some  manipulation 
delivered  through  the  wound.  A  large  fibroid  tumour  could 
now  be  felt  filling  the  pelvis.     To  get  access  to  this   tumour 


BY   DR   N.    T.    BEE  WIS. 


51 


it  was  necessary  to  empty  the  uterus.  To  do  so,  a  longitudinal 
incision,  about  3  inches  in  length,  was  made  in  the  anterior 
uterine  wall.  Through  this  the  five-and-a-half  months'  foetus 
was  delivered,  the  placenta  was  expressed,  and  the  uterine 
incision  sutured.  It  was  now  possible  to  draw  the  tumour 
out  of  the  pelvic  cavity,  where  it  was  found  to  be  growing 
from  the  posterior  aspect  of  the  supravaginal  portion  of 
the  cervix.  Supravaginal  hysterectomy  was  performed  in 
the  usual  manner.  The  cervical  mucosa  was  removed;  the 
vaginal  vault  was  perforated,  and  a  gauze  drain  passed  down 
into  the  vagina.  The  abdominal  incision  was  stitched  in  layers. 
The  patient  made  a  most  satisfactory  recovery. 

On  section,  the  central  portion  of  the  tumour  presented  the 
characteristic  appearance  of  a  fibroid,  but  surrounding  this  and 
towards  the  surface  there  was  extensive  degeneration.  The 
tissues  were  much  broken  down,  the  spaces  thus  formed  being 
filled  with  glairy-like  substance. 


The  operation  just  described  took  place  on  the  2nd  of 
November,  and  on  the  following  day  Case  No.  II.  went  into 
labour,  and  a  similar  operation  was  performed  on  her,  thus 
forming  a  notable  example  of  the  interesting  phenomenon, 
which  most  medical  men  have  experienced,  of  rare  cases  coming 
in  sequence. 

The  following  are  the  chief  points  of  interest  in  the 
history : — 

The  patient,  33  years  of  age,  has  been  ten  months  married. 
There  is  no  history  of  any  previous  pregnancy  or  abortions. 

Menstruation  began  at  13,  was  regular,  lasted  five  days, 
and,  until  two  years  ago,  presented  no  abnormalities.  For 
the  past  two  years  there  has  been  a  dull  dragging  pain,  chiefly 
in  the  iliac  regions  and  upper  parts  of  the  thighs,  during  the 
menstrual  period.  There  has  never  been  any  intermenstrual 
discharge.     For  some  time  there  has  been  increased  frequency 


52     CASES    OF   PREGNANCY   COMPLICATED   BY  FIBROID  TUMOURS, 

of  micturition,  but  neither  pain  nor  difficulty.  Albumen  was 
present  in  the  urine. 

Patient  last  menstruated  from  the  7th  to  12th  February 
1906.  In  the  latter  part  of  April  1906  patient  had  severe 
sickness,  and  was  confined  to  bed  for  two  or  three  weeks.  On 
getting  up  she  experienced  severe  pain  in  the  left  side.  This 
was  at  times  agonising  in  its  severity,  and  was  most  marked  in 
the  left  iliac  region.  The  pain  persisted  for  three  or  four  weeks, 
and  then  gradually  became  less  severe.  When  the  pain  had 
subsided,  the  patient  was  examined  by  her  doctor,  who  told  her 
she  was  pregnant,  and  also  that  she  had  a  tumour ;  he  kept  her 
confined  to  bed  for  seventeen  weeks.  I  saw  her  in  consulta- 
tion at  the  end  of  August  1906,  when  I  found  her  six  months 
pregnant.  Growing  from  the  left  side  of  the  uterus  there  was 
a  hard  tumour,  which  filled  the  greater  part  of  the  pelvic  brim. 

The  patient  was  most  anxious  to  have  a  living  child,  and, 
as  the  symptoms  were  now  not  so  severe  as  they  had  been, 
we  decided  not  to  interfere  until  the  full  term.  I  ordered  the 
patient  an  abdominal  belt,  and  advised  her  not  to  remain 
in  bed.  The  support  obtained  from  the  belt  had  the  desired 
effect :  there  was  no  recurrence  of  the  abdominal  pain. 

The  patient  came  into  my  Home  on  27th  October,  and 
subsequent  to  that  date  was  under  my  personal  observation. 
On  3rd  November  she  complained  of  pain  all  day  at  intervals ; 
this  was  felt  chiefly  in  the  back,  and  did  not  tend  to  radiate 
to  the  front.  At  4  p.m.  the  membranes  ruptured.  At  6  p.m. 
the  cervix,  on  vaginal  examination,  was  found  to  be  soft,  but 
only  sufficiently  dilated  to  admit  the  tip  of  the  index  finger. 
The  foetal  head  was  found  on  the  right  side  of  the  abdomen, 
above  the  pelvic  brim.  On  the  left  side,  also  just  above  the 
brim,  there  was  a  firm  rounded  mass,  about  the  size  of  a  foetal 
head.  Attached  to  the  uterine  wall,  about  2  inches  above 
and  to  the  left  of  the  umbilicus,  there  was  a  projection  which, 
through  the  abdominal  walls,  felt  like  a  foetal  foot  and  leg. 


BY   DR   N.    T.    BREWIS.  53 

At  7  p.m.  the  patient  was  anaesthetised  and  a  thorough 
examination  made.  The  head  was  found  -still  above  the  brim, 
which  it  was  prevented  from  entering  by  the  tumour.  The 
cervix  was  still  undilated.  As  the  liquor  amnii  had  drained 
away  some  hours  before,  and  the  child  had  consequently  been 
exposed  to  severe  pressure  between  the  fibroid  and  the  strongly 
acting  uterus,  it  was  decided  that  labour  should,  alike  in  the 
interests  of  mother  and  child,  be  terminated  as  quickly  as 
possible.  The  safest  method  for  both  was  undoubtedly  Csesarean 
section. 

The  abdominal  cavity  was  opened  by  an  incision  extending 
2  inches  above  the  umbilicus.  The  uterus  was  brought  into  the 
wound.  The  obstructing  tumour  was  found  to  be  a  fibroid 
situated  on  the  left  side  of  the  lower  uterine  segment ;  it  was 
rounded  in  shape  and  about  the  size  of  a  cricket  ball.  The 
projection  from  the  body  of  the  uterus,  described  above,  was 
found  to  be  an  irregularly  shaped  subperitoneal  fibroid  situated 
about  lh,  inches  internal  to  the  insertion  of  the  left  round 
ligament.  The  bladder  had  markedly  hypertrophied  walls  and 
was  found  to  reach  to  an  abnormally  high  level. 

The  uterus  was  opened  by  an  incision  about  4  inches  long 
in  the  anterior  wall.  Through  this  the  child  was  delivered  and 
the  placenta  removed.  The  uterine  incision  was  then  sutured 
with  thick  catgut.  The  tumour  was  next  shelled  out  of  the 
uterine  wall.  In  spite  of  all  efforts  to  promote  uterine  action, 
the  organ  remained  in  a  relaxed,  flabby  condition.  Owing  to  its 
atonic  state  and  the  consequent  oozing,  it  was  found  necessary 
to  perform  supravaginal  hysterectomy. 

The  child,  though  small,  was  in  no  way  malformed. 

Mother  and  child  returned  home  well  twenty-eight  days 
after  operation. 

Remarks. — The  presence  of  fibroid  tumours  in  the  uterus 
may  complicate  pregnancy,  parturition,  and  the  puerperium  in 


54      CASES    OF   PREGNANCY   COMPLICATED   BY   FIBROID   TUMOURS, 

a  variety  of  ways.  The  site  which  the  growth  occupies  is  the 
chief  factor  in  determining  the  significance  of  the  complication. 
For  example,  subperitoneal  growths  in  the  body  of  the  uterus, 
unless  of  considerable  size,  may  not  give  rise  to  any  symptoms 
during  pregnancy,  and  may  not  interfere  with  the  progress  of 
parturition ;  while  a  tumour  growing  in  the  lower  pole  of  the 
uterus  may  give  rise  to  severe  pressure  symptoms  during 
pregnancy,  and  may  constitute  a  complete  barrier  to  the  passage 
of  the  f oetus  through  the  pelvis  during  labour.  An  intra-uterine 
growth  may  interfere  with  the  development  of  the  product  of 
conception  and  lead  to  abortion,  with  risks  of  haemorrhage  and 
sepsis,  or  may  hinder  delivery,  or  cause  post-partum  haemorrhage. 
Therefore  pregnancy  may  occur  in  a  uterus  the  seat  of  a  fibroid  ; 
but  such  a  tumour  may  cause  no  symptoms  during  pregnancy, 
and  need  cause  no  anxiety.  Here  we  may  leave  nature  to 
safely  terminate  the  labour.  On  the  other  hand,  a  fibroid 
tumour  may  so  complicate  a  pregnancy  that  not  only  are  the 
symptoms  during  pregnancy  urgent  and  severe,  but  its  presence 
may  place  the  patient's  life  in  jeopardy  when  labour  sets  in. 
The  cases  which  I  have  just  related  belong  to  this  class.  The 
first  was  an  example  of  a  tumour  causing  distress  and  danger 
during  pregnancy,  the  second  was  an  example  of  a  tumour  caus- 
ing danger  during  labour.  When  it  is  clear  that  a  pregnancy, 
complicated  by  fibroid  tumour,  requires  surgical  treatment,  it 
is  possible  that  the  case  may  be  treated,  and  scientifically 
treated,  by  more  methods  than  one,  though,  doubtless,  there 
must  in  each  case  be  one  method  better  than  any  other.  In  my 
opinion,  this  applies  to  Case  No.  II.,  but  not  to  Case  No.  I. 

The  propriety  of  the  treatment  adopted  in  Case  No.  I.  could 
not  be  questioned.  The  tumour  filled  the  pelvis,  and  could  not 
be  dislodged ;  it  presented  an  impassable  barrier  to  the  transit 
of  the  child;  its  presence  was  a  menace  to  life,  and  caused 
symptoms  which  could  no  longer  be  endured  by  the  patient. 
The  indications  were  so  urgent,  there  was  no  alternative  but  to 


BY  DR  N.   T.    BREWIS.  55 

operate  without  delay  in  the  interests  of  the  mother.  The 
only  method  other  than  the  one  adopted  would  have  been  to 
remove  the  tumour,  leave  the  uterus,  and  thus  give  the  mother 
a  chance  of  carrying  the  foetus  to  term.  This  did  not  occur  to 
me  at  the  time,  but  an  examination  of  the  specimen  shows  that 
such  a  method,  however  ideal,  was  in  this  case  impracticable. 

In  Case  No.  II.,  the  tumour  gave  rise  to  no  urgent  symptoms 
during  pregnancy,  and  in  this  case  our  treatment  was  to  be 
planned  and  carried  out  with  the  view  of  saving  both 
mother  and  child,  or,  better  still,  mother,  child,  and  uterus. 
The  possible  procedures  that  occur  to  me  other  than  the  one 
carried  out  are  two  in  number : — 

1.  Labour  might  have  been  induced  at  the  seventh 
month  and  the  tumour  removed  subsequently.  Against  this 
plan  we  have  to  consider  the  risk  of  the  induction  to  the 
mother,  the  risk  of  losing  the  child,  and  the  subsequent  major 
operation  for  removal  of  the  tumour. 

2.  The  tumour  might  have  been  removed  without  interfering 
with  the  pregnancy.  This  might  have  been  attempted,  but 
there  were  not  sufficient  grounds  to  ensure  the  successful 
carrying  out  of  this  procedure. 

As  events  turned  out,  this  result  would  not  have  been 
attained  without  difficulty  and  danger.  The  tumour  was  placed 
under  the  bladder,  was  sessile,  and  had  a  broad  attachment  to  a 
very  vascular  part  of  the  uterus,  and  haemostasis  would  have 
been  difficult  and  uncertain.  The  question  of  whether  the 
fibroid  uterus  should  be  sacrificed  after  removal  of  the  child 
and  the  tumour  was  considered,  and  decided  in  the  affirmative : 
first,  on  account  of  the  uncertainty  of  being  able  to  deal  satis- 
factorily with  the  bed  from  which  the  tumour  had  been 
removed  ;  and  secondly,  from  the  fact  that  the  remainder  of  the 
body  of  the  uterus  was  not  healthy.  I  think,  as  events  proved, 
the  course  which  we  followed  was  right  and  proper.  The 
mother  and  a  healthy  child  were  saved,  and  the  former  returned 


56      CASES    OF   PREGNANCY   COMPLICATED   BY   FIBROID   TUMOURS. 

home  well  and  strong ;  and,  though  deprived  of  the  power  of 
bearing  offspring  in  the  future,  I  think  that,  after  her  experience, 
she  will  be  glad  that  such  an  event  is  not  possible. 


Dr  James  Ritchie  said  they  were  very  much  indebted  to 
Dr  Brewis  for  having  submitted  these  two  very  interesting 
cases.  The  class  of  case  referred  to  was  one  of  extreme  gravity 
in  practice.  When  one  discovered  a  cervical  tumour  in  a 
married  woman,  it  was  often  a  matter  of  great  difficulty  to  know 
how  to  treat  the  case.  Although  the  tumour  might  not  be  very 
large  at  the  beginning  of  pregnancy,  it  would  probably  grow 
very  much  during  pregnancy.  Should  immediate  operation  be 
recommended,  or  waiting?  He  thought  Dr  Brewis  had  put 
before  them  very  clearly  the  rules  for  guidance  in  such  cases. 
It  would,  he  thought,  be  well  to  explain  to  the  patient  the 
greater  danger  of  waiting  for  operation  till  full  term  rather  than 
having  it  dealt  with  at  a  comparatively  early  stage  of  preg- 
nancy; and,  having  given  the  explanation,  to  allow  the  patient 
to  choose  between  early  operation  and  waiting  events.  In  the 
first  case  there  was  no  doubt  about  the  procedure  which 
should  be  adopted. 

Dr  Lamond  Lachie  thanked  Dr  Brewis  for  the  report  of 
two  such  interesting  cases.  He  said  it  was  quite  clear  that  Dr 
Brewis  had  adopted  the  best  possible  means  of  saving  those 
patients,  but  remarked  that  it  was  curious  how  in  some  cases 
nature  so  frequently  seemed  to  overcome  difficulties  that  at  first 
sight  seemed  insuperable.  The  most  interesting  case  he  had 
seen  of  pregnancy  complicated  by  fibroid  tumour  was  of  a  lady 
who  had  come  to  Edinburgh  on  account  of  a  fibroid  tumour  com- 
plicating pregnancy,  diagnosed  by  her  doctor.  Dr  Lackie  in 
examining  per  vaginam  had  found  it  absolutely  impossible  to 
feel  any  os.     The  pouch  of  Douglas  was  entirely  occupied  by 


PKOGNOSIS  OF  PKEGNANCY  IN  PATIENTS  WITH  ONE  KIDNEY.      57 

the  fibroid.  It  was  determined  to  leave  the  patient  for  a  time, 
and  perform  Cesarean  section  at  a  later  date.  At  eight  months 
labour  set  in,  and  at  once  preparation  was  made  for  Cesarean 
section.  Labour  went  on  very  rapidly,  and  on  examination  it 
was  found  that  the  cervix  had  descended,  and  the  os  was  lying 
practically  in  the  centre  of  the  pelvis,  so  that  the  fibroid  tumour 
which  had  occupied  the  pouch  of  Douglas  had  risen  up,  and 
the  head  of  the  child  presented  in  the  normal  way.  After  the 
birth  of  the  child  the  os  had  ascended  again,  and  the  pouch  of 
Douglas  was  again  occupied  by  the  tumour,  and  it  was  found 
necessary  to  give  chloroform  and  hook  the  cervix  down,  pass  in 
the  hand,  and  remove  the  placenta.  The  patient  made  a  good 
recovery,  and  went  home  with  the  tumour  very  much  less  in 
size  than  it  had  been  during  pregnancy. 

Dr  Keppie  Pater  son  asked  if  Dr  Lackie  had  followed  up  the 
case,  but  Dr  Lackie  replied  that  he  had  not  done  so. 

Dr  Brewis,  in  reply,  said  the  case  cited  by  Dr  Lackie  might 
have  been  a  pedunculated  fibroid. 


VIII.  ON  THE  PROGNOSIS  OF  PREGNANCY  IN 
PATIENTS  WITH  ONE  KIDNEY,  WITH  NOTES  OF 
AN  UNUSUALLY  COMPLICATED  CASE  OF  LABOUR 
AFTER  NEPHRECTOMY. 

By  James  Haig  Ferguson.,  M.D.,  F.R.C.P.E.,  F.R.C.S.E.,  F.R.S.E. ; 

Assistant  Gynaecologist,  Royal  Infirmary,  Edinburgh;  Assistant 
Physician,  Royal  Maternity  Hospital,  Edinburgh  j  and  Gynaecologist, 
Leith  Hospital. 

In  recent  years,  owing  to  the  brilliant  and  rapid  advances  of 
surgery,  the  operation  of  nephrectomy  has  become  no  uncommon 
procedure  for  various  diseased  conditions  of  the  kidney.  It 
follows  that  we  as  obstetricians  will  occasionally  be  confronted 
with  the  question :  Should  a  woman  with  one  kidney  be  advised 


58  PROGNOSIS  OF  PREGNANCY  IN  PATIENTS  WITH  ONE  KIDNEY, 

to  marry  and  run  the  risk  of  becoming  a  mother?  I  am 
assuming,  of  course,  that  the  remaining  kidney  is  healthy  and 
equal  to  its  duties  in  ordinary  circumstances. 

We  know  that  during  pregnancy  in  healthy  women  the 
kidneys  undergo  hypertrophic  changes  of  a  strictly  physiological 
character,  so  as  to  enable  them  to  cope  with  the  increased  work 
they  have  to  do.  In  the  same  way,  as  is  well  known,  the  one 
healthy  kidney  in  the  patient  whose  diseased  kidney  has  been 
removed  undergoes  hypertrophy,  which  probably  began  long 
before  the  nephrectomy  was  performed,  the  diseased  kidney 
having  in  all  likelihood  been  more  or  less  functionless  for  a 
considerable  time  prior  to  operation.1  If  in  such  a  case 
pregnancy  should  then  supervene,  further  hypertrophy  will  be 
required  to  meet  the  necessary  demands;  and  as,  so  to  speak,  all 
the  patient's  eggs  are  now  in  one  basket,  any  undue  strain  on 
this  kidney  will  at  once  mean  very  serious  renal  insufficiency. 

The  case  I  am  about  to  record  shows  that  in  a  patient 
whose  remaining  kidney  is  healthy,  and  has  had  time  to  become 
sufficiently  hypertrophied  to  perform  the  work  of  two,  the 
strain  of  pregnancy  can  be  fairly  well  borne ;  for  although  the 
patient  developed  albuminuria,  and  had  a  diminished  excretion 
of  urea,  yet  when  she  was  put  on  proper  treatment  (though  it 
was  somewhat  late  in  the  day)  the  condition  yielded  fairly 
satisfactorily  to  appropriate  remedies,  and  the  kidney  irritation 
tended  to  subside.  In  fact,  this  patient  with  only  one  kidney 
had,  on  the  whole,  less  severe  albuminuria  and  less  toxic  dis- 
turbance than  many  albuminuric  primigravidse  both  of  whose 
kidneys  are  known  to  be  organically  sound,  though  it  is  possible, 
and  indeed  probable,  that  in  my  patient's  case  the  amount  and 


1  In  one  case  recorded  in  the  discussion  on  Mr  Twynam's  paper  on 
nephrectomy  in  pregnancy  {Lancet,  vol.  i.,  1898,  p.  165),  it  is  stated  that 
after  removal  of  one  kidney  in  a  man,  for  laceration,  where  all  the  work 
was  thrown  suddenly  on  the  opposite  organ,  the  amount  of  urine  and 
urea  became  normal  in  four  days'  time. 


BY  DK   JAMES    HAIG   FERGUSON. 


59 


virulence  of  the  toxin  or  toxins  she  was  manufacturing  were 
comparatively  insignificant.  It  is  manifestly  impossible  to 
institute  comparisons  between  different  patients  on  this  point. 

The  only  other  instance  of  which  I  have  personally  known 
where  pregnancy  occurred  in  a  patient  with  one  kidney,  was  in 
the  case  of  a  lady  who  was  married  about  two  years  ago,  after 
having  had  nephrectomy  performed.  Pregnancy  shortly  super- 
vened, and  she  died,  I  understand,  of  eclampsia  shortly  after  a 
premature  labour. 

One  would,  on  the  whole,  I  think,  prefer,  so  far  as  one's 
limited  knowledge  goes,  that  patients  who  only  possess  one 
kidney,  even  though  it  is  apparently  a  healthy  one,  should,  if 
they  marry  at  all,  delay  marriage  till  after  the  menopause. 
One  could  not,  however,  give  such  uncompromising  advice ;  it 
would  be  impracticable,  and  indeed  in  many  cases  hardly 
justifiable,  besides  being  highly  unwelcome  to  many  of  the 
recipients.  Each  case  would  require  to  be  judged  on  its  own 
merits,  and  after  a  careful  consideration  of  all  the  attendant 
circumstances.  Some  patients  might  be  determined  to  take  a 
certain  extra  risk  for  reasons  all-important  to  themselves,  and 
such  are  apt  to  listen  to  no  arguments  which  in  any  way  run 
counter  to  their  own  views  and  inclinations.  I  should  be 
strongly  inclined  to  urge,  in  the  interests  of  prudence,  that 
marriage  be  delayed  till  at  least  three  years  from  the  operation 
of  nephrectomy,  so  as  to  give  the  remaining  healthy  kidney 
ample  time  for  compensatory  changes  to  occur  under  the 
influences  of  the  varying  vicissitudes  of  ordinary  life — in  fact 
to  establish  and  consolidate  a  condition  of  matters  which  will 
enable  the  one  kidney  safely  and  easily  to  do  the  work  usually 
undertaken  by  two. 

Of  course  if  the  remaining  kidney  were  diseased,  marriage, 
where  there  is  any  possibility  of  child-bearing,  should,  in  my 
opinion,  be  out  of  the  question. 

Whenever  a  first  pregnancy  occurs  in  a  patient  with  only 


60     PROGNOSIS  OF  PREGNANCY  IN  PATIENTS  WITH  ONE  KIDNEY, 

one  kidney,  she  should  be  most  carefully  watched,  and  placed 
in  circumstances  where  this  watching  can  be  thoroughly  and 
systematically  carried  out,  her  urine  being  examined  and  tested 
regularly  during  the  whole  duration  of  pregnancy,  with  the 
view  of  immediately  bringing  the  pregnancy  to  an  end  should 
she  show  any  evidences  of  renal  inadequacy  which  fail  to 
respond  to  general  treatment. 

Special  care  should  be  taken  to  ensure  that  the  excretion  of 
urea  is  not  diminished,  and  in  this  connection  it  is  well  to 
remember  that  the  excretion  of  urea  in  healthy  pregnant 
women  seems  to  be  considerably  less  than  is  usually  supposed, 
varying,  according  to  Whitridge  Williams,  from  20  to  24 
grammes  in  the  twenty-four  hours.  I  have  certainly  in  some 
cases  verified  this  observation,  but  was  inclined  to  put  it  down 
to  commencing  failure  of  excretion,  and  diminishing  power  in 
the  kidney  function,  in  fact  to  commencing  toxaemia.  Be  this 
as  it  may,  there  can  be  no  doubt,  as  Marx  has  shown,  that  urea 
is  always  diminished  in  the  toxaemia  of  pregnancy,  and  that 
this  diminution  is  a  much  more  valuable,  and  certainly  an 
earlier  indication,  than  either  the  presence  of  albumen  or  casts, 
both  of  which  latter  may  be  absent  even  in  bad  cases.  If  this 
were  more  generally  recognised  and  acted  on,  there  would,  I 
feel  sure,  be  fewer  cases  of  eclampsia  than  we  now  have  to 
deplore. 

The  same  general  principles  would  hold,  as  regards  sub- 
sequent pregnancies,  in  the  case  of  a  parous  woman  who  had 
been  the  subject  of  nephrectomy,  always  bearing  in  mind  the 
fact  that  primigravidae  are  more  specially  liable  to  the  toxaemic 
disturbances  which  may  be  associated  with  pregnancy. 

The  same  remarks  might  be  applied  in  the  case  of  a  woman 
with  one  kidney  f unctionless,  as,  for  example,  in  hydronephrosis, 
or  where  only  one  kidney  is  diseased  and  the  other  healthy,  as 
proved  by  Luy's  separator  or  by  catheterising  the  ureters.  In 
such  cases  of  kidney  disease  it  would  be  of  great  importance  to 


BY   DR   JAMES   HAIG   FERGUSON.  61 

discover  the  exact  condition  of  each  kidney,  for  in  my  opinion 
the  prognosis  as  regards  the  supervention  of  pregnancy  would 
be  worse  with  two  kidneys  even  slightly  diseased,  than  where 
only  one  kidney  is  diseased  (even  considerably  so)  and  the 
other  healthy.  The  advantage  one  has  in  the  case  of  the  woman 
with  only  one  kidney  is  that  one  knows  exactly  where  one  is  as 
regards  the  condition  of  the  remaining  kidney,  and  can  speak 
therefore  with  a  more  certain  voice  as  regards  probabilities  and 
possibilities. 

I  have  been  unable  to  find  much  information  in  literature 
on  this  subject.  There  is  a  considerable  number  of  cases 
recorded  where,  on  account  of  urgent  kidney  complications, 
nephrectomy  had  to  be  performed  during  the  actual  existence 
of  pregnancy,  in  many  cases  with  satisfactory  results  both  as 
regards  the  mother,  the  continuance  of  the  pregnancy,  and  the 
health  of  the  child. 

Fritsch  says  that  pregnancy  can  be  carried  through  with 
nephrectomy  of  one  side,  and  quotes  a  case  of  Bovee's  in 
support  of  this.  He  says,  however,  that  the  remaining  kidney, 
if  it  becomes  in  a  higher  degree  a  "pregnancy  kidney,"  may 
easily  become  insufficient,  and  that  this  may  lead  at  once  to 
the  most  serious  eclampsia.  Schramm,  quoted  by  Cumston, 
records  a  case  where  the  right  kidney  had  been  removed  and 
pregnancy  and  labour  were  practically  normal.  He  sums  up 
by  saying  that  a  patient  having  but  one  kidney  may  go  through 
pregnancy  and  labour  without  any  injury  to  her  health,  but  it 
is  probable  that  such  a  patient  would  have  diminished  resisting 
power  should  she  be  afflicted  with  chronic  nephritis,  and  that 
an  attack  of  eclampsia  would  be  fatal  to  her.  In  other  words, 
with  good  fortune,  she  may  pass  through  her  pregnancy  and 
labour  safely,  but  any  breakdown  will  necessarily  tend  to  be 
greater,  and  therefore  apt  to  be  more  disastrous. 

The  variety  of  the  complications  which  had  to  be  dealt  with 
in  the  following  case  was  greater  than  I  have  ever  before  met 


62     PROGNOSIS  OF  PREGNANCY  IN  PATIENTS  WITH  ONE  KIDNEY, 

with  in  any  one  patient,  and  the  cases  must  be  few  in  which  so 
many  obstetrical  difficulties  have  been  concentrated  in  one 
individual.  For  in  addition  to  the  fact  that  she  had,  some 
years  previously,  undergone  the  operation  of  nephrectomy,  the 
patient  was  the  subject  of  albuminuria,  and  had  besides  a 
contracted  pelvis,  placenta  prsevia,  and  a  cervical  polypus, 
whilst,  in  the  way  of  obstetric  operations,  induction  of  labour 
and  craniotomy  were  required,  and  manual  removal  of  an 
adherent  placenta  was  necessary,  in  order  to  complete  the  third 
stage. 

The  notes  of  the  case  are  as  follows : — 

F.  K,  aet.  36,  a  primigravida,  was  admitted  to  the  Edinburgh 
Maternity  Hospital  at  9.30  p.m.,  on  the  29th  December  of  1905. 

The  patient  had  last  menstruated  on  the  20th  of  March 
1905,  and  on  admission  it  was  noted  that  in  spite  of  the  fact  of 
her  being  a  primigravida,  and  in  the  last  month  of  gestation, 
the  foetal  head  was  not  engaged  in  the  pelvis,  but  was  freely 
movable  above  the  pelvic  brim.  The  foetus  lay  in  the  left 
occipito-anterior  position. 

The  patient  stated  that  she  was  quite  well  during  her 
pregnancy  till  the  end  of  October  1905,  when  her  legs  became 
so  much  swollen  that  she  had  to  go  to  bed,  where  she  remained 
for  a  week.  She  had  been  liable  to  occasional  severe  head- 
aches. 

On  28th  December,  the  day  before  her  admission  to  hospital, 
she  was  suddenly  seized  with  severe  headache,  and  flashes  of 
light  before  her  eyes,  but  she  noticed  no  swelling  of  hands  or 
face.  On  admission,  her  urine,  which  was  scanty,  contained  2 
grains  of  albumen  and  4  grains  of  urea  per  fluid  ounce.  She 
was  thin  and  very  pale,  and  there  was  considerable  dropsy  of 
the  lower  limbs,  of  the  abdominal  wall,  and  of  the  vulva. 

When  five  years  of  age  she  had  had  scarlet  fever,  followed 
by  nephritis.  In  February  1896,  her  left  kidney  was  removed 
for  tuberculous  disease.     The  symptoms  which  led  up  to  the 


BY    DR   JAMES    HAIG    FERGUSON.  63 


nephrectomy  and  which  had  lasted  for  twelve  months  before 
the  operation,  were  progressive  emaciation,  blood  in  the  urine, 
frequency  of  micturition,  night-sweats,  and  attacks  of  severe 
pain  in  the  left  lumbar  region.  She  states  that  she  recovered 
well  from  the  operation,  but  that  the  wound  did  not  heal  for 
twelve  months  afterwards.  Since  then  she  has  remained  well. 
She  has  now  no  pain  or  discomfort  on  micturition,  but  passes 
water  rather  frequently — every  two  hours  or  so. 

Menstruation  began  when  she  was  16. years  of  age,  and 
recurs  at  intervals  of  twenty-four  days.  It  is  fairly  profuse. 
She  has  no  dysmenorrhoea  or  intermenstrual  discharge. 

Examination  of  the  pelvis  showed  an  intercristal  diameter 
of  10 \  inches,  and  an  interspinous  diameter  of  8f  inches.  The 
diagonal  conjugate  was  fairly  normal,  just  slightly  under  4J 
inches.  The  pelvis  was,  however,  much  contracted  transversely, 
and  was  of  a  kyphotic  type. 

The  patient's  general  condition  improved  under  milk  diet 
and  complete  rest  in  bed.  Her  urine  increased  in  quantity 
up  to  50  to  60  fluid  ounces  per  diem.  The  urea  varied  from 
2 J  to  4  grains  per  fluid  ounce,  and  the  albumen  decreased 
to  0*4  grains  per  fluid,  ounce. 

In  view  mainly  of  the  head  not  having  entered  the  pelvis, 
it  was  decided  to  induce  labour,  as  there  seemed  some  hope 
of  getting  the  head  through  if  it  were  not  too  firmly  ossified. 
Accordingly  a  bougie  was  introduced  into  the  uterus  on  the 
evening  of  3rd  January  1906.  There  was  some  bleeding 
per  vaginam  after  this,  and  this  was  at  the  time  attributed 
to  a  small  polypus  which  projected  inwards  from  the  left  side 
of  the  cervical  canal.  There  were  occasional  transient  pains 
during  the  next  twelve  hours,  and  at  the  same  time  some 
further  bleeding,  not  severe,  but  more  than  seemed  to  be 
accounted  for  by  the  cervical  polypus.  On  careful  examina- 
tion after  the  os  became  patent,  there  was  found  to  be  a 
lateral  placenta  praevia,  with  apparently  a  somewhat  shrivelled 


64     PROGNOSIS  OF  PREGNANCY  IN  PATIENTS  WITH  ONE  KIDNEY, 

placental  lobe.  The  pains  almost  disappeared  during  the  next 
twenty-four  hours  (even  though  the  membranes  had  ruptured 
prematurely),  and  there  was  not  much  haemorrhage.  On  the 
morning  of  5th  January  1906,  a  Champetier  de  Eibes's 
bag  was  inserted  through  the  os,  which  was  about  the  size 
of  a  florin  and  very  rigid.  Strong  pains  came  on  during  the 
day,  and  at  3  P.M.  the  patient  was  looking  and  feeling  very 
much  worn  out,  her  pulse  being  118  to  the  minute.  At 
3.30  p.m.  she  was  anaesthetised,  the  Champetier's  bag  was  pulled 
slowly  down,  so  as  to  fully  dilate  the  cervix,  as  well  as  to 
stretch  the  vagina  and  perinaeum,  the  forceps  was  applied 
to  the  foetal  head,  and  every  effort  was  made  to  effect  delivery 
in  this  way.  All  such  attempts,  however,  proved  futile, 
as  the  head  was  too  large  and  too  firmly  ossified  to  pass  through 
the  pelvic  brim.  I  therefore  performed  craniotomy,  and  the 
child  was  even  then  with  difficulty  extracted,  as  both  the 
cavity  and  outlet  of  the  pelvis  were  likewise  transversely 
contracted.  The  child  was  delivered  at  4.25  p.m.,  it  was  a 
male,  weighing  5  lbs.  13  oz.,  and  was  22  inches  in  length. 

The  placenta  was  retained,  and  after  half  an  hour  I  inserted 
my  hand  into  the  uterus,  found  it  completely  adherent,  and 
verified  the  diagnosis  of  partial  placenta  praevia.  After 
manually  detaching  and  removing  the  placenta,  an  intra- 
uterine douche  was  given,  and  it  was  found  necessary  to  insert 
three  stitches  into  the  perineum  The  placenta  showed  a 
shrivelled  lobe. 

The  puerperium  was  uneventful.  The  albumen  steadily 
diminished  and  ultimately  entirely  disappeared,  and  the 
patient  was  discharged  well  on  the  twelfth  day. 

This  case  is  mainly  of  interest  from  the  fact  of  the  patient 
having  only  one  kidney  with  which  to  face  the  strain  of  her 
first  pregnancy  and  labour.  Clearly,  labour  should  have 
been  induced  at  a  much  earlier  date  in  order  to  have  been 
of  any  service  in  giving  the  child  a  chance  of  life,  but  unfortu- 


BY  DR  JAMES   IIAIG   FERGUSON.  65 

nately  the  patient  did  not  come  under  observation  until  too 
late  for  this  operation  to  have  been  of  any  real  advantage 
in  the  child's  interests,  and  it  was  done  therefore  more  for  the 
mother's  sake  than  from  any  great  hope  of  saving  the  child. 

It  is  to  be  noted  that  the  patient  had  a  history  of  nephritis 
after  scarlet  fever  in  childhood,  from  which  she  seems  com- 
pletely to  have  recovered,  at  least  in  so  far  as  the  right  kidney 
was  concerned.  Her  left  kidney  was  removed  for  tuberculous 
disease  in  1896,  nearly  ten  years  before  her  confinement,  so 
that  during  all  these  years  she  had  manifestly  been  entirely 
dependent  on  the  right  kidney  for  all  her  renal  functions. 
Fortunately  this  kidney  proved  to  be  healthy,  and  rose  to 
the  occasion  most  satisfactorily.  But  if  it  was  equal  to  the 
work  required  of  it  in  the  non-gravid  state,  the  strain  implied 
by  the  occurrence  of  pregnancy  and  labour,  and  the  increased 
functional  activity  necessarily  produced  thereby,  set  up  a 
condition  of  relative  insufficiency,  which  fortunately,  however, 
did  not  go  the  length  of  a  complete  breakdown.  Had  the 
pregnancy  chanced  to  have  been  multiple,  or  had  the  toxaemia 
been  greater,  one  could  hardly  have  hoped  for  a  favourable 
result. 

Eeferences. 

In  the  Handbuch  der  Geburtshiilfe,  by  von  Winckel  (Wiesbaden, 
1904),  Zweiter  Band,  ii.  Teil,  page  1432,  practically  all 
the  references  to  kidney  operations  during  pregnancy 
are  given.  The  reference  to  Twynam's  case  is  given 
erroneously  under  "  Frymann." 

Also,  "Pregnancy  and  Labour  following  Nephrectomy,"  by 
Baldwin,  Cleveland  Medical  Journal,  1903,  ii.,  p.  213. 


Dr  Brewis  said  he  had  listened  with  pleasure  to  the  most 
interesting  paper  from  Dr  Haig  Ferguson,  and  thanked  him  for 
bringing  the  case  before  the  Society.     Dr  Ferguson  had  referred 

E 


66     PROGNOSIS  OF  PREGNANCY  IN  PATIENTS  WITH  ONE  KIDNEY. 

to  the  scarcity  of  instances  of  pregnancy  occurring  in  the  case 
of  a  patient  with  only  one  kidney.  He  had  looked  over  his 
records  and  found  that  in  April  1896  he  had  removed  the  right 
kidney  from  a  Mrs  B.,  and  that  in  August  1898  Mrs  B.  had  a 
child.  He  was  told  that  there  was  no  complication  at  all  in  the 
labour,  and  that  the  patient  was  still  quite  well. 

Dr  James  Ritchie  said  they  had  listened  to  a  very  interest- 
ing paper.  When  asked  to  attend  a  lady,  he  advised  her  to 
inform  him  should  increased  frequency  of  micturition  occur, 
or  if  there  was  too  small  a  quantity  of  urine,  or  if  there 
was  any  swelling  of  the  limbs.  If  the  patient  was  otherwise 
healthy,  he  did  not  make  further  examination.  If  the  patient 
were  known  to  have  an  abnormal  condition  of  the  urine,  it 
was  one's  duty  to  have  the  urine  frequently  examined  during 
the  whole  time  of  pregnancy;  if  the  patient  be  known  to  have 
only  one  kidney,  one  should  make  perfectly  sure  that  that 
kidney  was  acting  well  by  examining  as  to  quantity  of  urine 
passed,  its  specific  gravity,  and  the  amount  of  urea. 

Dr  Fred.  Porter  asked  Dr  Haig  Ferguson  why  in  the 
management  of  the  case  of  labour,  having  diagnosed  a  contracted 
pelvis  and  partial  placenta  praevia,  turning  had  not  been 
attempted  With  regard  to  albuminuria  and  one  kidney  only, 
and  Dr  Ferguson's  advice  for  the  woman  not  to  marry  till  the 
menopause,  he  considered  the  advice  rather  hard,  and  until  one 
knew  what  albuminuria  and  eclampsia  were  really  due  to,  he 
would  not  advise  non -marriage.  He  had  had  an  experience  of  a 
lady  who  had  become  pregnant  after  nephrectomy,  and  though 
the  case  had  not  been  under  his  care,  he  knew  that  she  had  a 
child  two  years  after  the  nephrectomy,  and  that  it  was  an 
absolutely  simple  labour,  and  the  child  was  still  living 

Dr  Haig  Ferguson,  in  reply,  said  that  he  did  not  say  he 
advised  a  woman  not  to  marry  under  such  circumstances.  As 
to  the  treatment  carried  out,  the  placenta  prsevia  was  not 
diagnosed  till  the  membranes  had  ruptured,  and  it  was  a  \ery 


SUCCESSFUL   TREATMENT   OF   PUERPERAL   FEVER.  67 

partial  placenta  prsevia;  the  lobe  presenting  was  somewhat  con- 
tracted. Further,  one  could  not  have  turned  well  in  a  kyphotic 
pelvis  with  a  narrow  outlet.  Even  if  the  condition  had  been 
recognised  earlier,  he  did  not  know  that  he  would  have  con- 
sidered version  as  at  all  a  practical  procedure  in  the  circum- 
stances. 

IX.   SUCCESSFUL   TREATMENT  OF  PUERPERAL  FEVER 
BY  ANTISTREPTOCOCCIC  SERUM. 

(Abstract.) 
By  Dr  Garnet  Leary  (Communicated  by  the  Secretary). 

In  this  communication  the  author  gives  his  experience  of  anti- 
streptococcic serum  in  the  treatment  of  cases  of  puerperal  sepsis 
occurring  during  1900-1902  in  an  extensive  club  and  mixed-class 
practice  Eecovery  took  place  in  all  the  cases,  this  successful 
result  being  ascribed  to  the  combined  and  persistent  use  of  in- 
tra-uterine  douches  along  with  the  administration  of  the  serum. 

At  the  onset  of  symptoms  of  infection  intra-uterine  douches 
of  corrosive  (1  in  1000)  or  creoline  (51  to  pint)  were  generally 
given  twice  or  three  times  daily,  carbolic  (1  in  40)  being 
substituted  after  a  few  days.  In  cases  where,  after  the  lapse 
of  two  or  three  days,  no  improvement  took  place  in  pulse  and 
temperature,  and  whenever  the  temperature  rose  to  103°  F.  to 
104°  F.,  and  pulse  to  120,  curettage  by  a  blunt  instrument  was 
performed,  and  fresh  antistreptococcic  serum  employed  and 
repeated  frequently,  according  to  the  severity  of  the  symptoms. 

Opportunities  for  making  microscopical  examination  or 
taking  cultures  were  not  available;  but  the  occurrence  of 
rigors,  high  fever,  rapid  pulse,  sweats,  diarrhoea,  and  marked 
wasting  distinguished  most  of  the  cases  as  of  true  streptococcic 
origin.  In  a  smaller  number  of  cases  the  symptoms,  while 
alarming,  were  less  severe,  and  yielded  to  intra-uterine  douching. 
In  these  the  infection  was  probably  saprophytic. 


68     SUCCESSFUL  TREATMENT  OF  PUERPERAL  FEVER  BY 

The  following  cases  are  detailed,  viz. : — 

Case  I. — Multipara,  set.  32,  with  previous  history  of  heart- 
disease,  was  seized  with  haemorrhage  at  sixth  month  of  preg- 
nancy, and  when  seen  some  hours  later  was  collapsed,  with 
almost  imperceptible  pulse.  The  os  was  dilated  to  the  size 
of -a  florin.  Pains  being  weak  and  hemorrhage  continuing,  a 
diagnosis  of  accidental  haemorrhage  was  made,  dilatation  com- 
pleted by  the  fingers,  and  a  six  months'  foetus  was  delivered  by 
forceps.  The  placenta  was  stripped  from  the  uterine  wall,  the 
uterus  irrigated  with  creoline  and  corrosive,  and  the  patient 
freely  stimulated.  As  collapse  continued,  saline  injections  were 
given,  foot  of  bed  raised,  legs  bandaged,  etc.  After  remaining 
semi- comatose  for  twenty  hours,  she  rallied  slowly  to  the  fourth 
day,  temperature  keeping  99°  F.  to  100°  F.  On  the  fourth  day 
the  temperature  rose  with  a  rigor  to  105°  F.,  pulse  168  and 
thready,  and  she  appeared  to  be  sinking.  Cold  sponging  and 
administration  of  quinine  and  phenacetin  causing  only  slight 
temporary  improvement,  10  c.c.  antistreptococcic  serum  were 
injected  into  the  abdominal  muscles.  This  was  followed  at  first 
by  another  rigor  and  rise  of  temperature,  but  in  six  to  ten  hours 
temperature  fell  to  102°  F.,  and  pulse  was  stronger  and  152. 
Another  injection  was  given  and  followed  by  another  rise  in 
temperature  to  104°  F.,  and  a  third  injection  twelve  hours  later. 

Next  day  temperature  was  100°  F.,  pulse  140,  and  patient 
showed  much  general  improvement,  becoming  for  the  first  time 
able  to  mutter  a  few  words  and  to  recognise  those  around  her. 

Improvement  was  gradual  and  steady  from  this  point,  and 
patient  was  able  to  leave  her  bedroom  in  two  months.  After 
a  few  months  further  treatment  for  her  heart  lesion,  she  was 
in  better  health  than  she  had  been  for  years. 

Case  II. — Multipara,  set.  28,  was  seized  with  profuse 
haemorrhage  at  the  eighth  month.  The  os  was  dilated  to  the 
size  of  a  crown  piece,  but  pains  were  few  and  feeble,  and  as 


ANTISTREPTOCOCCIC   SERUM,   BY   DR   GARNET   LEARY.  69 

haemorrhage  continued  profuse  and  edge  of  placenta  could  be 
felt  presenting,  the  membranes  were  artificially  ruptured, 
turning  effected,  and  the  uterus  plugged  by  traction  on  the 
foetal  legs.  After  saline  injections  and  stimulants  had  been 
given  to  combat  the  profound  collapse,  delivery  of  a  dead  foetus 
was  accomplished.  The  placenta,  which  was  adherent,  was 
then  removed  piecemeal  with  difficulty,  and  the  uterus  curetted 
and  douched.  Collapse  was  again  profound,  but  patient  rallied 
in  a  few  hours,  and  made  satisfactory  progress  until  the  third 
day,  when  septic  symptoms  supervened,  with  rapid  pulse,  pain, 
and  distension  of  abdomen,  accompanied  by  offensive  discharge. 
These  symptoms  continued,  in  spite  of  douching  twice  daily, 
until  the  sixth  day,  when  temperature,  which  had  been  101°  F. 
to  103°  F.,  rose  with  rigor  to  105°  F.,  pulse  140.  Intra-uterine 
douching  was  continued,  cold  sponging  done,  and  quinine 
sulphate,  phenacetin,  and  sodium  salicylate  given  internally, 
with  improvement  for  some  hours,  but  as  temperature  again 
rose  to  104°  F.,  10  c.c.  of  serum  was  injected.  Ten  hours  later 
temperature  fell  to  100-5°  F.,  pulse  120;  patient  began  to  take 
food,  and  looked  better.  Serum  was  repeated  next  morning. 
For  two  days  temperature  remained  between  100°  F.  and  102-5° 
F.,  pulse  100  to  120,  intra-uterine  douching  being  continued. 
A  third  injection  was  then  given.  The  symptoms  became 
greatly  improved,  but  further  complications  supervened  in  the 
form  of  pelvic  peritonitis  with  abscess  in  the  pouch  of  Douglas 
and  a  mammary  abscess.  The  administration  of  the  serum 
on  several  occasions  at  this  stage  seemed  to  give  beneficial 
results,  the  abscesses  being  also  incised  and  drained.  A 
threatening  abscess,  in  the  other  breast  seemed  to  be  aborted 
by  a  timely  injection.  Kecovery  was  then  rapid,  and  patient 
left  her  bed  some  three  weeks  later,  but  a  few  days  afterwards 
developed  phlegmasia  alba  dolens,  from  which  she  made  a  good 
recovery  after  six  weeks  treatment:  was  able  to  resume  her 
work  in  a  factory,  and  enjoyed  good  subsequent  health. 


70     SUCCESSFUL  TREATMENT  OF  PUERPERAL  FEVER  BY 

Case  III. — Mrs  C,  primipara,  was  delivered  by  forceps  of 
a  large  full-time  child  with  difficulty  because  of  hip-disease 
and  slight  pelvic  deformity.  The  perineum  was  torn  badly,  and 
stitched,  but  did  not  heal  well.  On  third  day  lochia  were 
offensive ;  temperature  99 '5°  F.,  pulse  104.  Intra -uterine  douches 
were  given  twice  daily,  stitches  removed,  and  edges  of  wound 
purified.  At  the  end  of  a  week,  during  which  temperature  kept 
from  100°  F.  to  102°  F.  and  pulse  100  to  130,  patient  had  a  rigor, 
and  gave  much  trouble  with  noisy  delirium.  During  the  next 
few  days  serum  was  injected  four  or  five  times,  each  dose  being 
followed  in  five  or  six  hours  by  marked  improvement.  The 
temperature  came  down  to  99°  F.,  pulse  108,  and  she  became 
quiet  and  rational,  and  took  more  nourishment.  Improvement 
was  steady  for  three  weeks,  when,  after  being  up,  abscesses 
developed  in  both  mammae,  and  slight  phlegmasia  alba  dolens 
came  on  in  left  leg.  Serum  was  used  for  both  conditions,  and 
appeared  to  markedly  ameliorate  the  symptoms.  In  six  weeks 
she  was  quite  well,  and  able  for  her  household  duties.  It  was 
subsequently  ascertained  that  the  midwife  in  attendance  on 
this  patient  had  come  to  her  from  attendance  on  a  fatal  case  of 
puerperal  septicaemia. 

Case  IV. — Mrs  O.,  multipara,  was  delivered  by  forceps  for 
tedious  labour,  a  small  perineal  tear  being  stitched.  The 
perineum  suppurated,  and  on  fourth  day  temperature  rose  to 
100°  F.,  pulse  108,  and  an  offensive  discharge  was  present.  In 
spite  of  douching,  temperature  and  pulse  continued  to  rise,  and 
on  sixth  day  curettage  was  done.  This  was  followed  on  eighth 
day  by  a  rigor,  and  patient  became  semi-comatose  for  several 
hours.  A  serum  injection  reduced  temperature  to  101°  F., 
pulse  115.  Next  day  another  rigor  occurred,  with  collapse  and 
unconsciousness  for  nearly  twelve  hours.  Patient  was  freely 
stimulated,  and  two  more  injections  of  serum  were  given.  Next 
day  temperature  was  100°  F.,  pulse  110,  and  general  condition 


ANTISTREPTOCOCCIC    SERUM,   BY   DR   GARNET   LEARY. 


71 


quiet  and  reasoning.  She  continued  to  make  a  remarkable 
recovery,  and  was  able  to  get  about  at  the  end  of  the  third 
week. 

As  Cases  II.,  III.,  and  IV.  occurred  in  succession,  at  a 
few  weeks  interval,  the  author  suggests  that  the  midwifery  bag 
may  have  been  instrumental  in  transmitting  the  infection, 
which  view  was  strengthened  by  the  cessation  of  the  series 
after  thorough  sterlisation  of  the  bag  and  its  contents. 


Case  V.  occurred  in  the  practice  of  Dr  T.  Leary,  J.P.,  father 
of  the  author,  in  1902.  Mrs  S.,  set.  20,  was  delivered  by 
forceps,  the  perineum  being  slightly  torn,  but  not  requiring 
stitching.  The  patient  progressed  normally  until  the  fourth 
day,  when  temperature  rose  to  101°  F.,  pulse  110.  Next  day  a 
slight  rigor  occurred,  accompanied  by  vertigo,  restlessness,  and 
some  delirium.  There  was  tenderness  in  the  left  iliac  region, 
and  diminished  lochia  and  milk  secretion.  Douching  twice 
daily  with  corrosive  sublimate  was  carried  out  up  to  seventh 
day,  when  temperature,  which  had  hitherto  kept  about  101°  F. 
to  102-5°  F.,  rose  to  104°  F.,  with  marked  exaggeration  of  the 
previous  symptoms.  The  pain  over  the  uterus  was  so  severe 
as  to  necessitate  morphia  suppositories.  Pulse  was  140,  of  good 
volume,  and  regular.  At  night  patient  became  prostrate  and 
semi-comatose,  and  showed  tremors  and  twitchings.  As  patient 
seemed  worse  next  morning,  antistreptococcic  serum  was  tried, 
on  the  suggestion  of  the  author.  The  improvement  by  the 
following  morning  was  remarkable,  and  temperature  had  fallen 
to  100°  F.,  pulse  116.  The  same  evening  another  injection  was 
given,  with  equally  satisfactory  result,  the  temperature  falling 
the  following  day  to  99-5°  F.,  and  the  diarrhoea,  which  had  been 
intractable  for  days,  ceased.  Four  days  later  a  relapse,  with  rise 
of  temperature  to  102°  F.,  pulse  100,  and  recurrence  of  pain, 
flushing,  and  diarrhoea,  yielded  promptly  to  other  two   serum 


72  SUCCESSFUL   TREATMENT   OF   PUERPERAL   FEVER   BY 

injections.  Progress  after  that  was  uninterrupted,  and  patient 
was  able  to  resume  her  household  duties  ten  days  later.  On 
searching  for  the  cause  in  this  case,  the  fact  was  elicited  that  a 
lodger  in  an  adjoining  room  was  suffering  from  erysipelas.  In 
this  case,  which  was  therefore  in  all  probability  a  pure  strepto- 
coccus infection,  the  serum  seemed  to  have  a  more  directly 
beneficial  effect  than  in  the  other  cases.  This  result  may  also 
have  been  due  to  the  more  frequent  repetition  of  the  dose,  as 
three  serum  injections  were  given  within  twenty-four  hours 
and  two  the  following  day. 

General  Remarks  and  Conclusions. — In  none  of  the  cases  did 
metastatic  abscesses  occur  as  the  result  of  the  use  of  the  serum, 
nor  was  any  local  suppuration  met  with.  The  serum  used  was 
always  fresh,  and  both  Burroughs  Wellcome's  and  Parke  Davis's 
preparations  were  used. 

After  referring  to  the  diversity  of  organisms  that  may  give 
rise  to  septic  conditions  after  labour,  including  different  varieties 
of  the  streptococcus,  Loeffler's  bacillus,  and  bacillus  coli,  either 
in  pure  or  mixed  infections,  as  accounting  in  some  degree  for 
the  apparently  contradictory  clinical  results  in  cases  where 
serum  has  been  employed,  Dr  Leary  summarises  his  conclusions 
as  follows : — 

1.  The  serum  should  be  used  in  all  cases  which  do  not  give 
way  rapidly  under  treatment  by  douching,  drugs,  etc. 

2.  A  bacteriological  examination  should,  if  possible,  be  made 
from  the  cervical  and  vaginal  discharge. 

3.  Frequent  repetitions  of  the  serum  should  be  given,  de- 
pending on  the  severity  of  the  case,  especially  noting  the  pulse. 

4.  Treatment  of  all  complications  that  may  arise  should 
include  use  of  the  serum. 


Dr  Keppie  Paterson  said  it  was  a  very  interesting  paper  to 
which  they  had  listened.     He  said  he  had  himself  used  serum 


ANTISTREPTOCOCCIC   SERUM,   BY   DR   GARNET   LEARY.  73 

in  two  of  his  cases  without  any  evident  benefit — in  one  case 
several  injections  had  been  given.  He  felt  that  the  injection  of 
serum  in  test  cases  of  fever  in  the  puerperium  was  very  much 
empirical  until  one  could  make  sure  what  germ  they  had  to 
deal  with.  In  one  of  his  cases  he  had  obtained  a  blood  culture, 
and  bacillus  subtilis  was  the  germ  found.  It  was  really 
necessary  to  obtain  a  culture  from  the  secretion  within  the 
uterus  and  from  the  blood  in  these  cases.  Then  one  might 
hope  to  benefit  the  patients  by  the  use  of  the  particular  serum. 

Dr  Lamond  Lackie  considered  that  an  intra-uterine  douche  of 
1  in  1000  corrosive  was  too  strong  to  be  used.  The  curettage  also 
was  not  a  very  satisfactory  treatment,  for  there  was  great  risk  of 
opening  up  new  channels  of  infection.  As  to  his  present  experi- 
ence of  the  use  of  antistreptococcic  serum,  it  had  been  eminently 
unsatisfactory.  Any  success  that  had  been  obtained  in  any 
case,  he  thought,  might  quite  well  have  been  due  to  the  local 
treatment — the  careful  washing  out  of  the  uterus  with  saline 
or  sterilised  water.  The  difficulty  was  to  know  exactly  what 
the  sepsis  was  due  to.  To  overcome  this  difficulty,  a  polyvalent 
serum  had  to  be  introduced,  made  from  various  species  of 
streptococcus,  and  that  form  of  serum  was  supposed  to  be  more 
able  to  counteract  the  poison.  But  it  seemed  to  him  that  one 
would  need  to  use  an  enormous  dose  of  the  serum  in  order  to 
give  the  antidote  of  the  particular  streptococcus  present.  In 
sapremia  the  serum  was  practically  useless,  but  with  local 
treatment  one  obtained  satisfactory  results.  In  real  cases  of 
septicaemia  one  would  like  to  have  a  serum,  but  serum  had  had 
no  effect  in  his  experience.  A  Committee  in  New  York  had 
come  to  the  conclusion  that  the  serum  was  absolutely  worthless 
in  these  cases.  In  cases  in  which  good  appeared  to  have  been 
obtained,  it  seemed  difficult  to  know  exactly  what  had  done 
good.  A  temperature  might  be  101°  F.  in  the  afternoon,  and 
next  day  it  might  be  normal,  the  fall  being  due  to  natural 
causes,  the  blood  alone  having  overcome  the  poison. 


74  SUCCESSFUL   TREATMENT   OF   PUERPERAL   FEVER. 

Dr  Haig  Ferguson  quite  agreed  with  Dr  Lackie  as  to  the 
failure  of  the  serum  to  do  any  good  even  in  cases  where  blood- 
cultures  and  the  secretion  in  the  uterus  had  been  examined 
and  the  streptococcus  found.  In  these  cases  one  would  have 
expected,  a  priori,  some  advantage  to  have  arisen  from  the 
exhibition  of  the  serum.  Personally,  however,  he  had  seen 
either  no  benefit,  or  very  little,  from  its  use.  As  to  scraping  the 
uterus,  it  was  a  dangerous  thing  to  do — opening  up  fresh  sur- 
faces. As  to  the  use  of  1  in  1000  corrosive  in  an  intra-uterine 
douche,  he  thought  it  to  be  very  dangerous  to  use  in  a  puerperal 
uterus.     Nothing  stronger  than  1  in  4000  should  be  employed. 


Meeting  III. — January  9,  1907. 
Dr  J.  W.  Ballantyne,  President,  in  the  Chair. 

I.  The  following  gentleman  was  elected  an  Ordinary  Fellow 
of  the  Society:— A.  M.  Crennan,  M.B.,  Ch.B.,  36  Woodburn 
Terrace,  Edinburgh. 

Dr  Haidtain  showed — (a)  TWISTED  PAROVARIAN  CYST  with 
an  intraligamentary  haemorrhage — the  ovary  not  being  at  all 
involved,  (b)  A  specimen  of  diffuse  uterine  fibrosis,  in 
which,  as  usual,  the  mucous  membrane  was  much  hypertrophied. 
(c)  A  sarcomatous  uterus,  round  celled,  which  filled  up  the 
entire  cavity,  perforated  the  wall,  and  involved  the  peritoneal 
cavity.  The  operation  had  been  performed  seven  or  eight 
months  ago,  and  at  present  the  patient  was  quite  well,  (d)  Uterus 
removed  for  perforating  abscess  of  its  wall.  The  case  was  one 
of  septicaemia  after  abortion.  On  opening  the  abdomen  it  was 
found  filled  with  purulent  material,  and  the  uterus  was  found 
perforated.  It  seemed  a  desperate  case ;  the  temperature  was 
about  104°  F.  at  the  time  of  operation,  but  the  patient  is  absolutely 


CASE  OF  ACUTE  ALBUMINURIA,  BY  DR  FREDERICK  PORTER.   75 

so  far  recovered,  (e)  Three  specimens  of  mucous  polypus  and 
adenomatous  growth,  associated  with  fibroid  uterus.  In  one 
of  the  specimens  the  mucous  polypus  is  growing  on  the  base  of 
a  fibroid.  (/)  A  multiple  fibroid  of  uterus,  giving  rise  to 
retention  of  urine.  The  special  interest  of  the  specimen  was, 
that  on  the  right  side  the  tube  seemed  as  if  it  had  passed  down 
into  a  sulcus,  which  seemed  to  be  formed  by  a  fibroid  in  the 
round  ligament,  which  had  turned  over.  But  the  condition  was 
a  very  difficult  one  to  understand. 


III.  CASE  OF  ACUTE  ALBUMINURIA,  CAUSED  BY  THE 
PRESSURE  OF  A  TUMOUR  ON  BOTH  URETERS- 
OPERATION— RECOVERY. 

By  Dr  Frederick  Porter. 

The  President  and  Fellows, — I  thought  this  case  of  suf- 
ficient interest  to  place  before  this  Society.  So  far,  I  have 
failed  to  find  any  record  of  a  case  presenting  a  similar  train  of 
symptoms,  but  there  is  possibly  some  Fellow  present  who  has 
had  experience  of  a  similar  case. 

Mrs  M'L.,  age  34,  multipara,  has  had  three  children,  youngest 
four  years  of  age.  All  her  labours  were  natural  and  easy.  I 
saw  this  patient  first  on  19th  April  1905,  when  she  complained  of 
general  weakness,  pain  in  the  back,  pain  in  the  right  hypochon- 
driac and  lumbar  regions,  especially  when  she  walked.  These 
symptoms  were  relieved  by  lying  down,  except  the  pain  in  the 
back,  which  was  more  severe.  She  informed  me  that  she  suf- 
fered from  the  above  symptoms  for  the  past  five  years,  and  con- 
sulted me  as  she  was  feeling  more  run  down  than  usual.  For 
the  last  six  or  eight  months  her  menstruation  was  regular  every 
twenty-one  days,  but  very  scanty,  the  period  lasting  one  day. 
There   was   slight   dysmenorrhea.     She   suffered  considerably 


76  CASE   OF   ACUTE   ALBUMINURIA, 

from  flatulence,  and  had  every  appearance  of  a  chronic  dyspeptic. 
Heart  and  lungs  were  apparently  sound.  There  were  no  hsemic 
bruits ;  pulse  74  per  minute ;  soft  tension. 

Abdominal  Examination  revealed  on  palpation  a  freely 
movable  tumour,  which  was  easily  palpable  on  deep  inspiration, 
and  with  slight  pressure  disappeared  from  the  hand  and  seemed 
to  dip  down  under  the  liver.  In  size  and  shape  it  seemed  to  me 
to  have  the  characteristics  of  a  large  kidney,  and  I  diagnosed 
the  case  as  a  movable  hydronephritic  kidney.  Eectovaginal 
examination  revealed  no  abnormality.  Urine  was  acid,  slight 
mucus-like  deposit,  no  albumen,  sugar,  or  blood.  Deposit  on 
microscopical  examination  revealed  a  number  of  large  squamous 
and  pyriform  cells,  and  a  few  leucocytes.  I  ordered  the  patient 
a  kidney  belt,  which  relieved  the  back  weakness,  but  with  no 
other  appreciable  results. 

I  examined  the  urine  at  intervals  of  a  month,  and  found  it 
always  practically  similar  to  my  first  examination.  One 
specimen  exhibited  a  larger  number  of  squamous  and  pyriform 
cells  and  leucocytes  than  any  previous  specimen. 

I  may  here  state  that  I  examined  this  patient's  urine  so 
frequently,  as  I  was  anxious  to  discover  the  significance  of  the 
presence  of  these  cells,  as  I  had  previously  observed  that  in 
several  urines,  and  as  I  thought  I  was  dealing  with  a  pure 
kidney  condition,  I  might  find  out  their  exact  nature.  I  will 
refer  to  this  later. 

History  of  Present  Illness. — On  3rd  November  1905,  patient 
complained  of  severe  headache. 

4th  November. — Headache  had  disappeared,  and  she  felt  in 
her  usual  health. 

5th  November. — She  complained  of  breathlessness,  with  a 
choking  sensation,  and  felt  sick.  She  lay  down  in  bed  for  an 
hour,  but  as  this  increased  the  above  symptoms,  she  rose  and 
sat  up  till  her  usual  bed-time.     She  slept  all  night. 

6th  November. — Complained  of  breathlessness,  but  rose  and 


BY   DR   FREDERICK   PORTER.  77 

did  her  house  duties.  She  noticed,  when  dressing,  there  was 
considerable  swelling  of  the  lower  limbs. 

7th  November. — Her  husband  noticed  there  was  swelling  of 
the  face  and  abdomen.  On  examining  the  legs  at  night  he  saw 
they  were  swollen  as  far  as  the  ankle.  She  complained  of  sick- 
ness throughout  the  day. 

8th  November. — On  dressing  in  the  morning,  she  found  she 
could  not  get  her  corsets  to  meet,  on  account  of  the  general 
swelling.  Her  arms  and  hands  were  greatly  swollen.  Other 
symptoms  similar  to  the  previous  day,  except  that  she  vomited 
twice.  I  was  asked  to  see  her  in  the  evening,  and  found  a 
general  oedema  of  the  whole  body.  Face,  arms,  hands,  chest, 
legs,  and  feet,  all  pitted  freely  on  pressure.  She  was  very 
breathless,  and  complained  of  pain  in  the  right  iliac  region,  and 
said  she  had  passed  a  small  teacupful  of  urine  in  the  twenty-four 
hours.  Pain  in  the  back  was  still  present,  but  she  was  quite 
free  from  pain  in  the  right  hypochondriac  region  (the  previous 
seat  of  pain).  She  had  very  severe  headache.  Pulse  was 
regular  (72  per  minute),  tension  high. 

Heart  on  Palpation. — Apex  beat  was  strong  and  heaving, 
and  was  shifted  about  \  inch  to  the  left. 

Auscultation. — Sounds  were  clear,  second  accentuated  and 
metallic ;  there  were  no  murmurs. 

Abdomen  was  distended  and  (edematous.  I  could  not 
detect  the  movable  tumour  in  the  right  hypochondriac  region ; 
over  the  right  iliac  there  was  resistance  on  palpation,  and  on 
deep  palpation  she  complained  of  pain.  Percussion  note  in 
this  region  was  duller  than  the  opposite  side,  and  remained  so 
after  patient  was  put  in  the  lateral  position. 

Urine  was  alkaline,  sp.  gr.  1022.  After  adding  acetic  acid 
and  boiling,  it  gave  a  copious  deposit  of  albumen  which  was 
almost  solid.     There  was  also  a  little  blood  present. 

Microscopically. — Eed  and  white  blood-cells,  a  large  amount 
of  epithelial  cells,  and  a  few  hyaline  casts. 


78  CASE   OF   ACUTE   ALBUMINURIA, 

As  I  assumed  my  previous  diagnosis  was  correct,  I  came 
to  the  conclusion  that  the  kidney  was  displaced  into  the  pouch 
of  Douglas,  and  the  ureter  had  become  twisted  in  the  process, 
thus  causing  the  nephritic  symptoms. 

Patient  was  given  a  saline  aperient  and  a  mixture  of  potass 
acetate,  hyoscyamus,  buchu,  etc.,  and  put  on  a  milk  diet. 

9th  November. — Headache  had  disappeared  ;  patient  passed 
a  normal  amount  of  urine,  which  contained  less  albumen ;  there 
was  no  blood,  but  casts  still  present.  Dr  Haultain  examined 
the  patient  in  the  evening,  and  practically  corroborated  the 
diagnosis.  On  vaginal  examination  he  found  a  body  lying  in 
the  pouch  of  Douglas,  which  he  thought  might  be  the  edge  of  a 
kidney. 

10th  November. — Patient  felt  better ;  headache  still  absent, 
and  she  was  less  cedematous ;  face  was  still  puffy,  but  there  was 
no  oedema  of  legs  and  arms.  In  the  evening  she  was  removed 
to  the  Deaconess  Hospital,  with  a  view  to  operation. 

She  remained  in  bed  till  15th  November,  where  she  felt 
quite  comfortable.  Urine  still  contained  a  considerable  amount 
of  albumen,  and  casts  were  still  present.  Mr  Alexis  Thomson 
operated,  and  removed  a  multilocular  pedunculated  cyst,  which 
was  attached  to  the  broad  ligament,  and  which  he  found  pressing 
on  both  ureters. 

Patient  remained  in  hospital  a  fortnight,  and  though  the 
operation  was  entirely  successful,  the  nephritic  symptoms  did 
not  improve,  but  steadily  got  worse.  I  believe,  while  in  hospital 
the  amount  of  albumen  was  estimated  for  the  first  day  or  two 
after  the  operation,  but  when  the  albumen  was  found  to  be 
increasing,  an  estimate  was  no  longer  taken.  I  regret  that  I 
have  no  accurate  notes  of  the  daily  output  of  albumen. 

When  patient  returned  home,  1  put  her  on  a  milk  diet,  gave 
diuretic  mixture  she  had  previously,  and  kept  her  in  bed. 
The  albumen  steadily  decreased  in  amount,  and  on  22nd  January 
(nine  weeks  after  operation)  there  was  no  trace.     On  question- 


BY   DR    FREDERICK    PORTER.  79 

ing  her  about  the  diet  she  got  in  hospital,  she  informed  me 
that  two  days  after  the  operation  she  had  been  on  an  ordinary 
convalescent  diet — chicken,  rabbit,  milk  pudding,  apple  tart, 
etc.,  and  this  no  doubt  accounted  for  the  increased  albuminuria. 

Her  after-history  was  without  interest,  except  that  I  found 
a  difficulty  in  getting  her  to  take  nitrogenous  food  without 
causing  a  return  of  the  albuminuria.  After  the  urine  was  free 
from  albumen,  I  waited  a  week  and  supplemented  the  milk 
diet  with  different  preparations  of  plasmon,  biscuits  and  powder, 
which  I  ordered  in  milk  puddings,  and  plasmon  cocoa  (this  was 
experimental).  I  found  on  this  diet  there  was  a  return  of 
albuminuria.  I  changed  the  diet,  and  gave  her  oatmeal  porridge, 
green  vegetables,  tomatoes,  milk  puddings,  and  milk  ad  lib. 
After  a  fortnight  there  was  no  return  of  albuminuria,  and  I 
gradually  introduced  chicken  soup,  veal,  tea,  etc. 

I  examined  her  urine,  at  first  fortnightly  and  then  monthly, 
but  found  no  trace  of  albuminuria.  She  is  now  on  an  ordinary 
light  mixed  diet,  and  she  is  in  every  way  better.  She  suffers  no 
pain  anywhere,  and  at  present  is  four  months  pregnant.  Her 
urine  is  free  from  albumen,  but  there  is  still  a  number  of 
squamous  and  pyriform  cells  present. 

This  case,  I  think,  may  strike  you  as  presenting  some  analogy 
to  the  albuminuria  of  pregnancy.  When  I  was  asked  to  see 
this  patient  on  8th  November  1905,  I  had  examined  her  urine 
ten  days  previously,  and  then  found  no  trace  of  albumen. 
Thus  there  is  no  doubt  the  albuminuria  was  of  sudden  onset. 
It  is  significant  also  that  the  movable  tumour  which  was 
situated  in  the  right  hypochondrium  was  no  longer  in  that 
position,  and  finding  a  dull  resistant  area  in  the  right  iliac 
region  (which  previously  did  not  exist),  I  feel  I  was  justified 
in  the  inference  that  the  tumour  was  displaced  into  the  pelvis, 
and  was  at  least  a  factor  in  causing  the  nephritis. 

As  the  operation  showed,  my  diagnosis  was  incorrect.  Had 
it  been  a  displaced  kidney  with  a  twisted  ureter,  then  I  think 


80  CASE   OF   ACUTE   ALBUMINURIA, 

the  symptoms  this  patient  suffered  from  might  all  have  been 
attributed  to  this,  with  some  possible  weakness  in  the  other 
kidney.  As  the  case  now  stands — "  a  tumour  attached  to  the 
broad  ligament  and  pressing  on  both  ureters"  (these  are  the 
surgeon's  words  for  what  he  found) — I  feel  that  I  cannot 
logically  conclude  that  this  could  be  sufficient  to  cause  such 
severe  symptoms  in  any  person  with  healthy  kidneys.  The 
question,  I  feel,  that  naturally  follows,  is :  Are  this  patient's 
kidneys  healthy,  or  are  they  in  a  state  of  nephritis  ?  From  text- 
book descriptions  of  symptoms  of  nephritis,  I  think  I  am  justified 
in  saying  that  this  patient  suffered  prior  to  the  displacement  of 
the  tumour,  and  does  not  at  the  present  time  suffer  from  nephritis. 
From  observations  I  have  made  on  urines  of  pregnant  and  other 
women,  and  with  my  present  knowledge  of  those  urines,  I 
believe  that  this  patient  suffered  from  some  catarrhal  condition 
of  one  or  both  kidneys,  and  I  arrive  at  this  decision  from  the 
condition  of  her  urine. 

I  fear,  Mr  President,  I  can  only  give  you  a  hypothetical 
reason  for  this  belief.  I  have  found  in  three  cases  I  have  met 
within  the  last  eight  months  a  similar  condition  of  the  urine  to 
this  patient.  In  two  of  those  cases  an  albuminuria  supervened, 
one  at  the  sixth  month  and  another  at  the  eighth  month  of 
pregnancy.  The  other  case  escaped,  and,  I  believe,  on  account  of 
a  very  strict  diet.  All  I  can  say  about  the  urines  of  those 
cases  is,  that  they  all  showed,  microscopically,  a  number  of  large 
squamous  and  pyriform  cells  and  leucocytes.  These  may  be 
cells  from  the  bladder,  as  authorities  on  the  subject  say  that 
cells  from  the  bladder  and  kidney  are  very  difficult  to  dis- 
tinguish. My  experience  (which  may  be  fallacious)  has 
taught  me  that  in  bladder  cases  it  is  seldom  those  cells  are  met 
with  so  freely  without  the  presence  of  pus,  and  whenever  I  find 
those  cells  persisting  in  a  urine,  I  always  examine  the  urine 
frequently,  and  place  the  patient  on  a  strict  diet,  as  I  believe 
they  are  suggestive  of  a  catarrhal  condition  of  the  kidneys. 


BY  DR    FREDERICK    POUTER.  81 

In  conclusion,  I  think  I  might  safely  say  that  if  this 
patient  had  not  sought  medical  advice  when  she  did,  and  I  had 
not  found  what  I  supposed  to  be  a  movable  kidney,  this  case 
might  have  been  diagnosed  as  a  case  of  uncomplicated  nephritis. 
The  lesson  this  case  has  taught  me  is  to  make  an  abdominal 
and  pelvic  examination  in  acute  albuminuria  in  women. 


The  President  said  that  the  Society  had  had  an  interesting 
case  record  put  before  it — one  that  presented  just  the  amount 
of  problematicalness  that  would  lead  to  different  opinions  as  to 
the  possible  causation.  Most  of  the  Fellows  were  familiar  with 
tumours  beginning  in  the  pelvis  and  growing  into  the  abdomen, 
and  thus  giving  rise  to  a  new  group  of  clinical  features,  e.g.,  in 
fibrosis  of  the  uterus.  According  to  Dr  Porter's  explanation, 
the  opposite  was  the  case  in  this  patient,  although  of  course  the 
cyst  must  have  been  down  in  the  pelvis  at  the  first,  and  had 
then  grown  up,  and  been  displaced  downwards  again.  The 
President  cited  a  case  where  a  tumour,  thought  to  be  a  kidney, 
had  been  displaced  downwards,  and  apparently  had  been  the 
cause  of  a  bad  attack  of  haemorrhoids.  Two  years  subsequently 
it  had  been  found  to  be  a  gall-bladder  full  of  gall-stones  which 
was  down  in  the  pelvis. 

Dr  Haultain  said  that  from  the  history  of  the  case,  from 
the  fact  that  the  tumour  had  been  felt  in  the  right  iliac  region, 
and  also  from  the  fact  of  the  albuminuria  (which  he  had  not 
seen  before  associated  with  tumours  of  ovary  or  uterus),  he  was 
led  to  believe  that  he  had  to  deal  with  a  kidney,  and  in 
accordance  with  his  belief  that  gynaecologists  should  only  take 
cases  associated  with  pelvic  organs,  he  had  asked  his  colleague, 
Mr  Alexis  Thomson,  to  see  the  case  and  give  his  opinion  upon 
it.  Mr  Thomson  had  been  vague  about  the  diagnosis,  but  had 
opened  the  abdomen,  while  he  (Dr  Haultain)  had  had  the 
pleasure  of  assisting  him,  and  had  found  an  ovarian  cyst.     He 

F 


82   CASE  OF  ACUTE  ALBUMINURIA,  BY  DR  FREDERICK  PORTER. 

thought  it  showed  one  the  great  importance  of  going  very 
thoroughly  into  these  cases,  but  that  however  thoroughly  one 
did  go  into  them,  that  sometimes  one's  diagnosis  must  be 
absolutely  wrong.  He  had  operated  upon  a  considerable 
number  of  ovarian  and  fibroid  tumours,  and  had  never  seen 
anything  like  the  amount  of  albuminuria  present  in  this  case. 
What  exactly  had  been  the  cause  of  it  was  difficult  to  say. 
There  had  been  no  great  dilatation  of  the  ureters,  but  it  seemed 
as  if  there  must  have  been  some  pressure  on  the  ureter  on  one 
side,  although  it  was  not  noticed  at  the  time  of  operation. 
Abdominal  section  had  been  indicated,  and  the  operation  was 
successful. 

Professor  Kynoch  said  he  had  had  pleasure  in  listening  to 
the  paper.  He  had  been  going  to  ask  if  there  had  been  any 
dilatation  of  the  ureter,  or  any  kinking  of  it,  but  Dr  Haultain 
had  already  said  there  was  not  any. 

Dr  Ritchie  said  that  Dr  Porter  had,  before  the  operation, 
diagnosed  a  movable  kidney.  What  was  the  condition  of  that 
kidney  after  the  operation?  One  of  the  practical  lessons  of 
this  case  was  that  when  albuminuria  was  present,  it  was  of 
great  importance  that  the  patient  be  dieted  very  carefully  till 
the  albuminuria  had  completely  disappeared. 

Dr  Porter,  in  reply,  thanked  the  Fellows  for  their  kind 
reception  of  the  communication.  As  to  Dr  Kitchie's  question, 
the  patient  had  a  general  slight  enteroptosis,  both  kidneys 
were  slightly  movable,  and  the  liver  slightly  displaced.  As  to 
the  suggestion  that  the  albuminuria  was  something  apart  from 
the  tumour:  it  might  have  been  so,  but  he  had  examined 
frequently  before,  and  knew  the  position  of  the  tumour,  then, 
called  in  suddenly  and  finding  no  tumour,  but  a  dullness  in  the 
right  iliac  region,  he  was  justified  in  taking  up  the  explanation 
he  had  given. 


HEMORRHAGE  AND  ARTERIOSCLEROSIS  OF  UTERINE  VESSELS.    83 


IV.     INTRACTABLE      UTERINE      HEMORRHAGE      AND 
ARTERIO-SCLEROSIS  OF  THE  UTERINE  VESSELS. 

By  Elizabeth  H.  B.  Macdonald,  M.A.,  M.D.,  Ch.B.,  Carnegie  Research 
Scholar,  University  College,  Dundee. 

Many  cases  of  severe  uterine  haemorrhage,  occurring  near  the 
menopause  and  without  obvious  cause,  have  been  reported  within 
recent  years.  The  pathological  findings  in.  these  cases  have 
been  almost  as  various  as  the  constructions  put  on  the  patho- 
logical conditions  in  the  attempt  to  explain  the  haemorrhage. 

Nearly  all  have  shown  thickened  blood-vessels,  and  the 
vessel  changes  have  been  regarded  by  many  observers  as  the 
causal  factor.  In  particular,  Eeinecke,  in  1896,  reported  four 
cases  where  hysterectomy  was  performed  for  bleeding,  and 
where  the  pathological  examination  showed  the  most  marked 
changes  to  be  in  the  vessels.  He  explained  the  hsemorrhage  as 
due  to  the  inability  of  the  thickened,  rigid  vessels  to  respond 
to  vasomotor  stimulation.  Cholmogoroff,  Pichevin,  and  Petit, 
and  more  recently  Barbour  and  others,  have  reported  similar 
cases.  But  the  connection  between  uterine  arterio-sclerosis  on 
the  one  hand,  and  uncontrollable  uterine  hsemorrhage  on  the 
other,  has  not  been  clearly  established.  Cases  are  known 
where  a  marked  sclerotic  condition  of  the  vessels  has  been 
unattended  by  haemorrhage,  and  the  occurrence  of  serious 
haemorrhage  has  been  noted  where  the  vessels  showed  no 
marked  change. 

Pozzi,  in  1899,  still  seeking  the  cause  of  haemorrhage  in  the 
condition  of  the  vessels,  differed  from  other  observers  in  finding 
the  thickening  in  and  around  the  vessel  walls  due  mainly  to  an 
increase  in  elastic,  and  only  to  a  less  extent  in  fibrous,  tissue. 
The  great  increase  in  the  elastic  tissue  of  the  organ  gave  to  it, 
he  considered,  a  peculiar  resistance,  and  paralysed  its  contracting 
power,  so  that  haemorrhage  readily  occurred.     Anspach,  on  the 


84   HEMORRHAGE  AND  ARTERIOSCLEROSIS  OF  UTERINE  VESSELS, 

other  hand,  in  a  recent  paper  (1906)  demonstrates  the  physio- 
logical increase  in  elastic  tissue  in  muciparous  uteri,  and 
suggests  that  the  cases  of  bleeding,  which,  as  being  in  his 
opinion  dependent  on  a  pathological  condition  of  the  muscula- 
ture, he  designates  "metrorrhagia  myopathica/'  may  be  due  to 
a  failure  in  the  normal  increase  of  elastic  tissue. 

Theilhaber,  noting  the  extreme  difficulty  of  distinguishing 
physiological  from  pathological  changes  in  the  blood-vessels  of 
an  organ  subject  to  such  functional  variations  as  the  uterus, 
and  believing  that  the  majority,  if  not  all,  of  the  changes 
described  as  arterio-sclerosis  are  conditions  normal  in  a  parous 
uterus,  lays  stress  on  the  part  played  by  the  musculature  in 
the  occurrence  of  haemorrhage.  But  exactly  the  same  difficulty 
in  distinguishing  what  is  pathological  from  what  is  physiological 
arises  here.  What  is  the  normal  proportional  increase  of 
fibrous  tissue  to  muscular  tissue  with  advancing  age  and 
repeated  pregnancies?  When  does  Theilhaber's  "muscular 
insufficiency  "  arise  ? 

Other  observers  have  sought  the  cause  of  the  haemorrhages 
in  ovarian  changes.  That  all  the  causes  have  a  very  definite 
connection  with  the  periodic  ovarian  stimulation  on  which 
menstruation  depends,  is  quite  clear  from  the  histories.  None 
of  the  patients  manifesting  uncontrollable  haemorrhages  of 
obscure  origin  was  past  the  menopause ;  and,  as  Barbour  justly 
remarks,  "Arterio-sclerosis  after  the  menopause  has  been 
frequently  described,  but  never  as  accompanied  by  serious 
haemorrhage." 

A  consideration  of  the  mode  of  occurrence  and  control,  so 
far  as  we  know  it,  of  the  normal  menstrual  haemorrhage,  may 
throw  some  light  on  the  causation  of  abnormal  uterine  haemor- 
rhages. It  is  clear  that  the  normal  haemorrhage  is  brought 
about  and  controlled  by  several  factors,  and  that  a  disturbance 
in  any  one  of  these  may  cause  irregularities. 

That  a  gradually  increasing  pelvic  congestion   occurs   and 


BY  DR   ELIZABETH   H.    B.    MACDONALD.  85 

culminates  in  haemorrhage  mostly  by  diapedesis,  but  partly  also 
at  the  height  of  the  congestion  by  rupture  of  some  of  the 
endometrial  capillaries,  has  been  sufficiently  demonstrated ;  as 
also  the  fact  that  this  periodic  congestion  is  dependent  on  the 
ovaries.  Whether  the  general  rise  of  blood  pressure  is  due  to 
an  internal  ovarian  secretion  exerting  its  influence  through  the 
blood,  or  is  determined  by  nervous  influences,  or  depends  on 
both  these  factors,  is  still  doubtful.  But  at  least  it  is  safe  to 
assume  that  variations  in  the  normal  stimulation  may  result  in 
abnormalities  of  menstruation. 

No  less  important  than  the  ovarian  stimulus  is  the  response 
of  the  uterus,  and  here  it  will  be  convenient  to  consider 
separately  the  response  of  the  musculature,  including  the  blood- 
vessels, and  of  the  endometrium. 

The  part  played  by  uterine  contractions  in  controlling 
haemorrhage  has  been  fully  described  by  Theilhaber.  He  points 
out  that  during  the  greater  portion  of  the  menstrual  period  the 
uterus  is  large  and  flabby;  then  contractions  occur  which 
become  gradually  longer,  while  the  bleeding  becomes  correspond- 
ingly less,  until  finally  the  flow  ceases  completely,  strong  and 
continued  contraction  being  necessary  for  this  complete  cessation. 
Similarly,  in  the  puerperium,  the  cessation  of  lochial  discharge 
is  dependent  on  contraction  of  the  muscle.  Thus,  he  argues,  if 
the  muscular  contraction  is  insufficient,  hyperaemia  results, 
with  its  probable  secondary  results  in  swelling  and  oedema  of 
the  uterine  parenchyma,  and  following  these,  long-continued 
monorrhagia  may  readily  occur.  Anspach  explains  the  actual 
occurrence  of  menstrual  haemorrhage  as  due  to  obstruction  to 
the  venous  return,  whereby  congestion  is  produced,  resulting 
naturally  in  diapedesis,  the  obstruction  being  caused  by  weak 
uterine  contractions  narrowing  the  veins,  but  failing  to  narrow 
in  a  corresponding  degree  the  thicker-walled  arteries.  This  is 
essentially  the  view  of  Theilhaber,  leaving  us  to  infer  that  the 
cessation  of   the  haemorrhage   will   be  brought  about  by  con- 


86    HEMORRHAGE  AND  ARTERIOSCLEROSIS  OF  UTERINE  VESSELS, 

tractions   strong   enough   to  close  the  arteries  as  well  as  the 
veins. 

Any  explanation  of   uterine   haemorrhage   that   even   only 
apparently  separates,  in  regard  to  its  action,  the  uterine  muscle 
from   the   blood-vessels,  appears  to  me  to  be  defective.     The 
uterus  may  be  ideally  considered  as  a  muscular  expansion  of 
the  vascular  walls,  as  Keiffer,  from  his  study  of  the  histology 
of  the  nervous  system  in  the  uterus,  points  out.     Vasomotor 
stimulation    causes    contraction    or   relaxation   of  the   whole 
uterus.     The  involuntary  muscle  of   the  vessel  walls  is  to  be 
regarded  as  essentially  part  of  the  uterine  musculature,  subject 
for  the  most  part  to  the  same  variations  and  the  same  patho- 
logical changes.     From  this  point  of  view  it  appears  possible 
that  during  the  height  of  menstrual  congestion   the   pressure 
within  the  vessels   is   such  as   to   paralyse   their  contracting 
power,  and  that  as  the  pressure  lessens,  partly  from  escape  of 
the  blood  and  partly  probably  from  natural  diminution  of  the 
ovarian  stimulus,  the  vessels  regain  their  tone,  and  the  uterus 
responds  to  the  vasomotor  stimulation  by  contractions  sufficient 
to  stop  the  haemorrhage.     For  the  complete   cessation   of   the 
flow,  strong  and  lasting  contraction  is   necessary,  but   this   is 
brought  about  as  a  response  on  the  part  of  the  entire  muscula- 
ture  to   vasomotor   stimulation.      It   follows   that  any   cause 
interfering  with  the  normal  response  of  the  musculature  may 
cause  irregularities  of  menstruation. 

The  response  of  the  endometrium  to  the  menstrual  stimulus 
is  important  and  interesting.  The  gradually  increasing  con- 
gestion causes  a  definite  swelling  of  the  mucosa,  so  that  the 
stroma  cells  become  more  distinct  in  outline  and  later  polyhedral 
from  mutual  pressure,  while  the  glands  appear  larger  from 
swelling  of  their  epithelial  cells.  The  surface  capillaries  show 
a  remarkable  power  of  distension  to  accommodate  the  increased 
supply  of  blood,  and  appear  also  to  increase  in  number,  so  that 
some  observers  have  thought  that  new  capillaries  are  formed. 


BY   DR   ELIZABETH   H.    B.    MACDONALD.  87 

But  it  is  possible  that  the  delicate-walled  collapsible  tubes 
become  apparent  only  when  in  a  more  or  less  distended  con- 
dition. The  actual  haemorrhage  occurs  by  diapedesis  through 
these  delicate  capillary  walls,  and  partly  also,  in  all  probability, 
by  rupture  of  some  of  them,  the  corpuscles  finally  forcing  their 
way  between  the  individual  cells  of  the  surface  epithelium,  or, 
by  dislodging  one  or  two  adjacent  epithelial  cells,  finding  a 
freer  exit. 

What  is  true  of  normal  haemorrhage  is  true  also  as  regards 
the  mode  of  occurrence  of  abnormal  uterine  haemorrhage. 
There  is  no  suggestion  in  any  of  the  recorded  cases  of  severe 
bleeding  that  rupture  of  the  presumably  diseased  vessels  had. 
occurred.  The  haemorrhage  occurs  by  capillary  oozing,  an  over- 
distension of  the  endometrial  capillaries  being  first  produced ; 
and  the  ease  with  which  haemorrhage  occurs  depends  to  a 
considerable  extent  on  the  healthy  condition  of  the  capillaries 
and  their  resisting  power.  One  would  expect,  therefore,  that 
any  disturbances  in  the  circulation,  whether  arising  from 
increased  arterial  supply  causing  over-filling  of  the  capillaries, 
or  from  venous  obstruction  producing  over-distension  by  back- 
ward pressure,  would  tend  to  produce  uterine  haemorrhage. 
And  there  is  little  doubt  that  such  circulatory  disturbances 
would  result  in  the  appearance  of  haemorrhage  much  more 
commonly  than  they  do,  were  it  not  for  the  peculiar  character 
of  the  endometrium,  its  unique  readiness  of  response  to  stimu- 
lation. 

So  far,  therefore,  the  causes  of  abnormal  uterine  haemorrhage 
fall  naturally  into  three  groups : — 

1.  Abnormalities  in  the  periodic  ovarian  stimulation. 

2.  Conditions  giving   rise  to  muscular  insufficiency,  either 

from 

(a)  actual  deficiency  of  muscular  tissue,  or 

(b)  loss  of  tone,  and  consequent  deficient  response  to 

vasomotor  stimulation . 


88    HAEMORRHAGE  AND  ARTERIO-SCLEROSIS  OF  UTERINE  VESSELS, 

3.  Conditions  giving  rise  primarily  to  continued  congestion 
of  the  endometrium,  either  from 

(a)  increased  arterial  supply,  or 

(b)  venous  obstruction. 

1.  Of  ovarian  changes  and  their  effect  on  menstruation,  we 
know  comparatively  little.  We  know  from  actual  experiment 
that  the  growth  of  the  uterus  depends  directly  on  the  healthy 
functional  activity  of  the  ovaries,  that  the  complete  removal  of 
the  latter  results  in  atrophy  of  the  uterus  and  of  the  genital 
organs  generally,  and  that  the  retention  of  even  a  small  piece 
of  healthy  ovarian  tissue  is  sufficient  to  prevent  these  regressive 
changes.  Physiologically,  there  is  a  gradual  lessening  of  ovarian 
activity  as  the  menopause  is  approached,  and  this  is  accom- 
panied by  these  general  regressive  changes,  atrophy  of  the 
uterine  muscle  and  mucosa,  thickening  of  the  walls  of  the 
vessels  with  narrowing  of  their  lumina,  and  the  gradual  cessa- 
tion of  menstruation. 

Menorrhagia  in  connection  with  ovarian  disease,  especially 
early  cystic  changes  in  the  ovary,  is  well  known  to  occur,  and 
was  noted  many  years  ago  by  Lawson  Tait.  The  haemorrhage 
in  these  cases  is  unaffected  by  curetting,  or,  indeed,  by  any 
treatment  save  removal  of  the  diseased  organ.  The  endome- 
trium often  shows  no  appreciable  change  from  the  normal — a 
noteworthy  point,  in  view  of  the  manifold  forms  of  change  which 
it  is  liable  to  show  in  cases  of  venous  congestion.  Exactly  how 
the  monorrhagia  is  brought  about  is  not  clear.  Brennecke's 
explanation  of  the  cases  which  he  named  "  endometritis  hyper- 
plasia ovarialis  "  was  based  on  Pfluger's  theory  that  menstrua- 
tion is  directly  dependent  on  ovulation.  But  this  theory  has 
since  been  shown  to  be  insufficient,  and  Brennecke's  explanation 
covered  only  those  cases  where  lasting  congestion  and  consequent 
hyperplasia,  with  monorrhagia  as  a  secondary  result,  occurred. 
Czempin  recognised  cases  of  severe  monorrhagia  unconnected 
with  endometrial  changes  occurring  in  association  with  adnexal 


BY   DR    ELIZABETH    H.    B.    MACDONALD. 


89 


diseases.  These,  he  suggested,  might  be  due  to  an  exaggeration 
of  the  normal  stimulation,  resulting  in  arterial  congestion  and 
consequent  severe  and  lasting  haemorrhage.  Since  the  men- 
strual stimulus  is  associated  essentially  with  an  increased 
blood  pressure,  producing  its  effects  in  the  uterus  by  creating  a 
sudden  hyperemia,  it  seems  reasonable  to  suppose  that  an 
exaggerated  stimulus  should  result  in  menorrhagia. 

The  probability  of  disturbed  ovarian  function  occurring  at 
the  menopause  is  readily  appreciated,  and  the  marked  con- 
nection between  the  approaching  menopause  and  uncontrollable 
uterine  haemorrhage  strongly  suggests  the  possibility  of  ovarian 
changes  being  a  causal  factor  in  the  haemorrhages.  Cases  of 
spontaneous  cure  occurring  when  ovarian  activity  ceases  and 
the  menopause  is  fully  established,  strengthen  this  possibility. 
Gardner  and  Gooclall,  in  a  recently  published  paper,  refer  to 
such  cases,  and  point  out  that  if  ovarian  stimulation  acting  on 
a  uterus  affected  by  "chronic  metritis"  is  the  cause  of  the 
menorrhagia,  then  the  menorrhagia  should  continue  until 
ovarian  function  ceases,  the  condition  of  the  uterus  remaining 
unaltered.  But  they  report  a  case  where  severe  menorrhagia, 
occurring  near  the  menopause  and  associated  with  all  the  usual 
signs  of  "chronic  metritis,"  disappeared  under  conservative 
treatment,  yet  normal  menstruation,  indicating  ovarian  activity, 
remained. 

It  is  interesting  to  note  that  several  of  the  reported  cases 
of  uncontrollable  haemorrhage  laid  to  the  charge  of  arterio- 
sclerosis or  muscular  deficiency  have  shown  ovarian  changes. 
Thus,  in  the  case  reported  by  Barbour,  the  right  ovary  was 
cystic,  with  very  little  ovarian  substance  left,  while  the  left  was 
small  and  sclerosed ;  and  of  Anspach's  three  cases  of  "  metror- 
rhagia myopathica,"  two  showed  ovarian  changes  to  a  slight 
extent. 

Further,  it  is  evident  that  impairment  of  the  functional 
activity  of  the  ovaries  may  occur  independently  of  any  demon- 


90    HEMORRHAGE  AND  ARTERIOSCLEROSIS  OF  UTERINE  VESSELS, 

strable  lesion,  and  may  be  the  cause  of  haemorrhage  in  those 
cases  where  no  pathological  condition  is  found.  Indeed,  Freund 
goes  so  far  as  to  say  that  only  in  cases  of  bleeding  from  car- 
cinoma has  an  anatomical  basis  for  the  haemorrhage  been 
demonstrated. 

2.  It  is  obvious,  from  a  consideration  of  the  part  played  by 
the  musculature  in  the  control  of  menstrual  haemorrhage,  that 
failure  of  the  muscle  to  contract  efficiently  may  be  associated 
with  haemorrhage  of  the  severest  kind.  Such  failure  may  be 
due  to 

(a)  actual  deficiency  of  muscular  tissue.  Thus,  insufficient 
muscular  development,  such  as  not  infrequently  obtains  at  the 
time  of  puberty ;  or  actual  atrophy  and  degeneration,  such  as 
occurs  normally  at  the  menopause  but  may  occur  as  a  premature 
and  so  far  pathological  change;  or  "sclerosis"  of  the  uterus, 
whether  due  to  a  primary  diathetic  condition  (Brionde,  Eichelot) 
or  a  secondary  result  of  infection  (Bland-Sutton),  all  come 
under  this  heading,  and  in  all  the  muscular  coat  of  the  vessels 
participates  in  the  pathological  changes.  Without  actual 
deficiency  of  muscle,  insufficient  contraction  may  be  due  to 

(b)  loss  of  tone  in  the  musculature.  This  may  occur  as  a 
simple  atony  associated  with  a  lowering  of  tone  throughout  the 
body  from  some  general  cause,  and  possibly  then  accompanied 
by  manifestations  of  muscular  atony  in  other  parts  of  the  body, 
gastric  symptoms,  etc.,  or  as  a  local  change  from  the  various 
causes,  producing  atony  of  the  uterine  muscle  either  directly  or 
through  fatigue  of  the  nerve- cells.  The  effects  of  various 
poisons,  of  alcoholism,  etc.,  on  the  nerve-cells  has  not  yet  been 
shown,  but  these  have  possibly  a  direct  effect  in  producing 
atony  of  the  musculaturei 

In  cases  of  menorrhagia  arising  from  this  cause,  intermen- 
strual leucorrhoea  is  a  not  infrequent  symptom,  the  explanation 
being  the  lowering  of  tone  in  the  vessel  walls  and  the  consequent 
ready  escape  of  leucocytes.     It  is  doubtful  whether  muscular 


BY  DK   ELIZABETH   II.    B.    MAC  DONALD.  91 

insufficiency  alone,  apart  from  this  element  of  lowering  of  tone, 
ever  gives  rise  to  leucorrhoea,  since  the  capillaries  in  a  healthy- 
condition  have  a  remarkable  power  of  resisting  pressure,  and 
accommodating  themselves  by  enormous  dilatation  to  an  in- 
creased mass  of  blood.  Typically,  deficiency  of  the  musculature, 
without  deficient  vitality  of  the  vessel  walls  from  loss  of  tone, 
will  result  in  menorrhagia,  the  hemorrhage  becoming  more 
prolonged  and  profuse  as  the  secondary  hyperplasia  of  the 
uterine  parenchyma  becomes  more  evident. 

It  is  in  this  class  that  Theilhaber  would  place  the  great 
majority  of  the  cases  of  uncontrollable  haemorrhage  occurring 
at  the  menopause,  and  in  this  he  is  enthusiastically  supported 
by  Palmer  Findley.  Normally,  the  regressive  changes  in  the 
musculature  associated  with  the  menopause  are  accompanied  by 
corresponding  regressive  changes  in  the  blood-vessels  which 
become  accommodated  to  a  decreased  blood  supply.  Anything, 
therefore,  preventing  this  normal  diminution  in  blood  supply, 
anything  keeping  the  blood  supply  at  its  former  level  in  face  of 
the  retrograde  changes  in  the  muscle,  will  cause  haemorrhage — 
haemorrhage  which  these  authors  regard  therefore  as  due  to 
muscular  insufficiency.  But  the  regressive  changes  in  the 
musculature  are  admittedly  physiological,  normal  at  the  meno- 
pause, and  would  not  give  rise  to  haemorrhage  were  it  not  that 
the  vessels  are  prevented  from  closing  proportionately.  It 
would  seem  more  logical,  then,  to  regard  the  haemorrhage  as  a 
result,  not  of  the  atrophied  condition  of  the  muscle,  which  is 
physiological,  but  of  the  patent  condition  of  the  vessels,  which 
is  pathological.  It  is  evident  that  a  normal  blood  supply  acting 
on  an  insufficient  musculature  will  have  the  same  practical 
result  as  an  increased  blood  supply  on  normal  musculature. 
The  question  is  whether  the  muscular  atrophy  is  premature 
and  therefore  pathological,  and  justly  to  be  blamed  as  the 
causal  factor  in  the  haemorrhage,  or  whether  the  blood  supply  is 
being  maintained  at  a  pathologically  high  level,  either  through 


92    HEMORRHAGE  AND  ARTERIOSCLEROSIS  OF  UTERINE  VESSELS, 

failure  to  diminish  when  it  naturally  should,  or  from  a  real,  and 
as  yet  unexplained,  increase  in  pressure. 

Although  many  of  the  reported  cases  of  intractable  haemorr- 
hage show  intermuscular  fibrosis,  with  atrophy  and  degeneration 
of  muscle,  yet  there  is  no  general  agreement  that  atrophy  of 
muscle,  beyond  that  occurring  normally  at  the  menopause,  is 
characteristic.  The  point  is  extremely  difficult  to  determine. 
Thus,  in  four  cases  reported  recently  by  Wittek,  three  show 
intermuscular  fibrosis,  and  the  fourth  does  not.  But  the  excep- 
tional case  was  a  nullipara.  Shaw,  investigating  cases  of  chronic 
metritis,  finds  no  marked  increase  of  connective  tissue  at  the 
expense  of  muscular,  but  rather  a  hypertrophy  of  both  elements, 
due,  he  considers,  to  efforts  on  the  part  of  the  uterus  to  rid  itself 
of  the  thickened  mucosa. 

Cases  of  haemorrhage  where  the  musculature  is  insufficiently 
developed,  or  where  its  atrophy  is  definitely  premature,  are 
undoubtedly  to  be  placed  in  the  category  of  myopathic  haemor- 
rhages. In  this  class  also  may  justly  be  placed  those  cases  which 
have  as  their  starting-point  an  acute  febrile  disease  such  as 
typhoid ;  or  are  associated  with  anaemic  conditions,  particularly 
chlorosis,  or  with  chronic  wasting  diseases,  such  as  phthisis. 
All  these  are  definitely  associated  with  changes  in  involuntary 
muscle,  and  show  their  effects,  as  a  rule,  on  the  heart.  Other- 
wise, changes  in  the  uterine  musculature  are  probably  for  the 
most  part  secondary  to  circulatory  disturbances. 

3.  Cases  of  intractable  uterine  haemorrhage  due  primarily  to 
circulatory  disturbances  form  an  important  group.  Continued 
congestion  of  the  endometrium  may  be  due  to 

(a)  an  increased  arterial  supply.  In  determining  this,  the 
endometrium  may  be  primarily  at  fault,  as  in  cases  of  direct 
infection,  placental  retention  where  the  remnants  act  the  part 
of  an  irritant  foreign  body,  and  malignant  disease  of  the  mucosa. 
Inflammation  and  tumours  of  the  adnexa,  as  also  tumour 
formation,  particularly  fibro-myoma,  in  the  uterus  itself,  will 


BY   PR   ELIZABETH   H.    B.    MACDONALD. 


93 


likewise  determine  an  increased  arterial  supply,  and  to  these 
may  be  added  any  local  irritation,  mechanical  or  psychical. 
Histologically,  as  Frennd  has  shown,  this  arterial  congestion 
will  be  characterised  by  an  increase  in  the  number  of  capillaries, 
and  a  widening  of  the  vessels,  in  which  naturally  the  veins  take 
part  more  readily  and  to  a  greater  extent  than  the  arteries,  the 
widening  in  the  veins  being  of  a  diffuse  character  affecting 
mostly  the  capillary  venous  network  on  which  the  strain  of  the 
increased  blood  supply  first  tells. 

(b)  Venous  obstruction  may  arise  from  a  general  condition, 
such  as  heart-  or  kidney-disease,  chronic  lung  affections,  chronic 
constipation,  etc. ;  or  from  local  obstructions  to  the  venous 
return,  such  as  would  be  caused  by  tumours  within  or  without 
the  uterus ;  or  from  displacements  of  the  uterus.  The  resulting 
passive  congestion  does  not,  according  to  Freuncl,  cause  any 
increase  in  the  number  of  capillaries,  but  results  first  in 
irregular  dilatation  of  the  larger  veins,  particularly  of  those  in 
the  fundus ;  the  pressure  may  further  tell  back  on  the  arteries, 
and  produce  thickening  of  their  walls. 

Long-continued  congestion  from  whatever  cause  arising, 
brings  about  a  very  typical  reaction  in  the  mucosa.  There 
appears  to  be  little  doubt  that  a  large  number  of  the  cases 
variously  described  as  "  hyperplastic  endometritis,"  "  hyper- 
trophic glandular  endometritis,"  "  interstitial  endometritis,"  etc., 
are  simply,  as  Van  Meerdervoort  describes  them,  secondary 
results  of  long-continued  congestion  of  the  mucosa.  The 
differences  in  the  various  forms,  including  "fungous"  and 
"  polypoid  endometritis,"  are  merely  of  degree,  and  he  suggests 
"  chronic  oedema "  as  a  more  correct  and  appropriate  title  for 
the  whole  class.  Lofquist  arrives  at  very  similar  conclusions, 
suggesting  that  all  the  various  changes  are  degrees  of  what  he 
terms  "  decidual  reaction."  The  changes  are  slow  and  gradual ; 
the  distension  of  the  capillaries  does  not  result  in  haemorrhage, 
as  in  the  more  rapid   menstrual   increase   in   blood   pressure, 


94   HEMORRHAGE  AND  ARTERIO-SCLEROSIS  OF  UTERINE  VESSELS, 

because  the  tissues  have  time  to  adapt  themselves  to  the 
increased  blood  supply.  Hyperplasia  of  the  tissues  results, 
affecting  first  the  mucous  membrane,  and  extending  in  the 
course  of  time  to  the  entire  uterus,  giving  one  of  the  forms  of 
"  chronic  metritis." 

Many  attempts  have  been  made  to  elucidate  "chronic 
metritis,"  some  observers  regarding  it  as  due  always  to  infection 
of  a  more  or  less  remote  date,  others  as  secondary  to  chronic 
endometritis,  others  as  a  primary  condition  giving  rise  to 
chronic  endometritis  by  interference  with  muscular  contraction 
and  consequent  hyperemia.  That  there  are  many  forms  of 
pathological  change  involved  and  so  far  confounded  is  probable. 
But  one  form  of  the  affection — where  the  uterus  is  generally 
enlarged,  with  thickened  walls  showing  no  evident  dispropor- 
tional  increase  in  fibrous  tissue,  but  rather  a  general  swelling 
and  hyperplasia  of  all  the  constituent  elements,  the  endome- 
trium at  the  same  time  exhibiting  one  or  other  of  the  usual 
forms  of  "glandular  endometritis" — is  almost  certainly  due 
primarily  to  a  disturbance  in  the  circulation.  This  is  the  form  of 
chronic  metritis  found  in  the  various  displacements  of  the  uterus. 

Clinically,  these  cases  are  characterised  by  a  gradually 
increasing  monorrhagia,  and  this  is  what  we  should  expect  from 
the  pathological  condition.  The  menstrual  stimulus,  normally 
resulting  in  a  comparatively  rapid  over-distension  of  the 
capillaries,  produces  its  effect  more  slowly  through  the  thickened 
mucosa  with  its  already  comparatively  distended  and  more 
numerous  capillaries,  but  when  haemorrhage  does  occur,  at  the 
very  height  of  the  congestion,  it  is  more  profuse  than  normal 
because  of  the  more  widely  distended  condition  of  the  capillaries. 
Similarly,  the  bleeding  will  last  longer,  partly  from  the  lowered 
tone  of  the  vessels  from  prolonged  dilatation,  and  partly  from 
inefficiency  of  the  oedematous  muscle,  together  resulting  in  less 
efficient  response  to  the  vasomotor  stimulation,  and  so  failure 
to  arrest  the  haemorrhage  with  normal  rapidity. 


BY  DR   ELIZABETH   H.    B.   MACDONALD.  95 

But  not   all  cases  of  venous  congestion  become  clinically 
apparent   as    menorrhagia.      Whether   abnormal    haemorrhage 
results,  appears  to  depend  to  some  extent  on  the  resisting  power 
of  the  endometrial  capillaries.     The  vessels  of  the  endometrium 
are  peculiar.      Macgregor   has   described   them   carefully,  dis- 
tinguishing between  the  "thick-walled"  and  the  "thin-walled" 
vessels.     The  latter  are  merely  tubes  lined  by  a  single  layer  of 
delicate  endothelium,  and  show  enormous  power  of  dilatation. 
The  "  thick-walled  "  vessels,  on  the  other  hand,  derive  support 
from  a  condensation   of   the   stroma   cells   around   them,  and 
these,  Macgregor   states,  while   showing  many  changes  in  the 
way  of   thickening  of   their   walls,  hyaline   degeneration,  etc., 
never   dilate.     This   is   open   to   question.      The   thick-walled 
vessels,  which  it  seems  hardly  correct  to  call  "  arterioles,"  may 
become  dilated  in  cases  of  long-continued  venous   congestion. 
This  was  well  shown  in  a  recently  observed  case  of  retroflexion, 
in   which   there   had    been    no    abnormal    haemorrhage.      The 
mucous  membrane  was  very  markedly  thickened,  giving  rise  on 
curetting  to  the  suspicion  of  malignancy,  and  its  appearances 
were  those  of  an  advanced  "  chronic  oedema,"  with  great  increase 
in  the  number  of  glands  and  swollen  stroma  cells  showing  their 
outlines  and  anastomosing  processes  in  great  perfection.     Most 
striking  was  the  large  number  of  dilated  "  thick-walled  "  vessels, 
of   globular   outline   and   with  a  marked  condensation  of  the 
stroma   around   them.      The   condition   was   produced   in    all 
probability  by  backward  pressure  from  the  long,  over-distended, 
thin- walled  capillaries,  the  healthy  nervous  tone  of  the  capillary 
vessels  preventing  the  relief  of   pressure   by  diapedesis.     The 
patient  in  this  case  was  comparatively  young,  32,  and  unmarried. 
Where  the  congestion  arises  from  an  increased  arterial  supply, 
there  is  a  tendency  to  metrorrhagia,  in  addition  to  the  menor- 
rhagia commonly  observed.    Any  sudden  stimulation,  mechanical 
or  otherwise,  determining  a  sudden  further  increase  in  the  blood 
supply,  may  cause  haemorrhage.     We   may  suppose   that   the 


96    HEMORRHAGE  AND  ARTERIOSCLEROSIS  OF  UTERTNE  VESSELS, 

explanation  is  a  sudden  dilatation  from  vasomotor  paralysis  of 
the  vessels  formerly  in  a  state  of  exaggerated  tonus. 

Influence  of  the  Menopause. — In  determining  the  causal  factor 
in  any  case  of  intractable  uterine  haemorrhage,  therefore,  many 
conditions  must  be  considered.  After  excluding  the  cases 
probably  arising  from  muscular  insufficiency  and  eliminating  all 
the  usual  causes  of  long-continued  congestion,  there  still 
remains  a  class  unexplained.  Yet  a  careful  consideration  of 
the  possible  known  causes  markedly  reduces  the  number  of 
these  obscure  cases.  Thus  the  patient  whose  case  is  reported 
by  Pichevin  and  Petit,  had  had  typhoid  at  30,  followed  by 
menorrhagia,  which  was,  however,  cured  by  a  supervening 
pregnancy,  but  returned  in  a  severe  form  demanding  hysterec- 
tomy after  another  pregnancy  two  years  later.  Again,  of 
Pozzi's  cases,  while  the  elastic  tissue  proliferation  on  which  he 
lays  stress  may  mean  nothing  more,  according  to  recent 
researches,  than  that  the  uteri  examined  were  parous,  one  case 
had  had  typhoid,  and  the  other  had  had  chlorosis,  and  at  the 
time  of  operation  had  albuminuria,  an  important  symptom  of 
increased  blood  pressure.  It  is  of  further  interest  to  note  that 
none  of  these  patients  was  very  near  the  menopause. 

Those  cases  becoming  evident  only  at  the  menopause  have 
probably  their  origin  in  circulatory  troubles,  the  congestion 
having  lasted  perhaps  for  years  previously  without  giving  rise 
to  any  troublesome  symptoms. 

We  do  not  know  how  ovarian  activity  acts  in  maintaining 
the  uterus  in  a  healthy  condition,  but  a  twofold  action  at  least 
suggests  itself.  The  periodic  vasomotor  stimulation  causing 
reflex  contraction  maintains  the  musculature  in  an  efficient 
working  condition ;  and  ovarian  secretion  in  some  obscure  way 
preserves  a  healthy  uterine  tone.  When  ovarian  stimulation 
begins  to  fail,  the  uterus  suffers  in  this  twofold  way,  so  that 
there  is  a  certain  amount  of  atrophy  from  disuse,  and  a  tendency 
to  degeneration  from  the  cutting  off  of  some  trophic  influence. 


BY   DR   ELIZABETH   H.    B.    MACDONALD.  97 

These  effects  will  be  equally  produced  in  a  uterus  already 
affected  by  hyperplasia  from  continued  congestion,  and  they 
are  sufficient  to  determine  the  disturbance  of  compensation 
which  results  in  monorrhagia.  The  menstrual  stimulation  is 
essential  in  starting  the  haemorrhage;  the  prevailing  uterine 
conditions  prevent  its  normal  arrest. 

Pathological  Changes  in  the  Uterine  Blood -vessels,  and  their 
Influence  in  Determining  Hemorrhage. — So  far  the  vessels  have 
been  dealt  with  as  essentially  part  of  the  uterine  musculature, 
and  in  no  way  to  be  regarded  as  of  primary  importance  in  the 
causation  of  haemorrhage.  But  arterio-sclerosis  has  been  so 
extensively  regarded  as  the  causal  factor  that  the  subject  deserves 
special  attention. 

There  can  be  no  doubt  that  the  vessel  changes  designated 
"arterio-sclerosis"  are  in  many  cases  normal  changes,  and  in 
no  way  to  be  regarded  as  responsible  for  the  occurrence  of 
uterine  haemorrhage.  Exactly  similar  changes  are  found  un- 
connected with  haemorrhage.  Marked  degenerative  changes, 
designated  by  Anspach  "periarterial"  and  "perivenous"  de- 
generation occur  normally  in  every  parous  uterus.  In  a 
specimen  stained  by  haematoxylin  and  eosin  these  areas  appear 
pink  with  few  and  scattered  nuclei ;  with  Van  Gieson's  picro- 
fuchsin  method  they  appear  a  brighter  yellow,  in  clear  contrast 
to  the  yellow  of  surrounding  muscle;  and  with  Weigert's 
resorcin-fuchsin  stain  for  elastic  fibres  they  take  a  dark  blue  or 
black  colour.  This  definite  increase  in  elastic  tissue  round  the 
vessels  is  characteristic,  and  appears  to  occur  during  the  puer- 
perium.  The  elastic  tissue  of  the  uterus  generally  is  increased 
with  every  pregnancy,  so  that  it  is  always  possible  to  tell  a 
parous  from  a  non-parous  uterus  in  a  Weigert  preparation.  The 
fine  elastic  fibrils  become  thickened  and  curled,  and  show  a 
tendency  to  clumping.  In  the  vessels,  the  inner  elastic  lamina  no 
longer  appears  as  a  clear,  unbroken,  wavy  fibre,  but  is  thickened 
and  broken  up,  and  there  is  an  increase  of  elastic  fibrils  through- 

G 


98    HEMORRHAGE  AND  ARTERIOSCLEROSIS  OF  UTERINE  VESSELS, 

out  the  media.  Melnikow-Easwendenkow  believes  that  the  place 
of  lost  parenchyma  in  any  organ  is  taken  by  elastic  tissue.  Pick 
records  a  case  of  uterine  haemorrhage  resisting  treatment  in  a 
woman  of  63,  which  may  have  been  due  to  an  evident  failure  in 
the  normal  increase  of  elastic  tissue  around  the  uterine  vessels. 

The  normal  involution  of  arteries  after  pregnancy  is  to  be 
distinguished  from  a  pathological  change.  Naturally  there  is 
enormous  hypertrophy  of  the  entire  musculature  in  the  gravid 
uterus,  with  new  formation  of  blood-vessels,  many  of  which 
must  undergo  entire  obliteration  during  the  process  of  involu- 
tion. This  is  brought  about  by  a  process  recognised  as 
"endarteritis  obliterans,"  in  which  there  may  be  enormous 
overgrowth  of  the  intima,  practically  occluding  the  vessel; 
contraction  of  the  new-formed  connective  tissue  throughout  the 
media  and  in  the  adventitia  helps  the  process.  Normally  there 
is  a  slight  increase  of  fibrous  tissue  at  the  expense  of  muscle 
when  involution  is  completed ;  the  vessels  share  in  this,  their 
adventitial  coats  being  relatively  slightly  thickened  after  each 
pregnancy.  It  appears,  therefore,  that  thickening  of  the 
intima,  with  irregular  increase  in  its  elastic  tissue,  thickening 
of  the  media,  with  increase  in  the  fibrous  tissue  of  both  media 
and  adventitia;  later,  degeneration  of  the  coats  and  of  the 
surrounding  tissue,  with  deposition  of  elastic  tissue,  may  all 
occur  as  physiological  changes. 

The  following  case,  in  which  the  uterus  was  removed  on 
account  of  severe  menstrual  pain,  and  which  is  probably 
primarily  one  of  glandular  endometritis  due  to  infection,  the 
changes  in  the  musculature  being  secondary,  shows  vascular 
changes  which  may  be  taken  as  physiological  for  a  uterus  with 
a  corresponding  history : — 

Mrs  K.,  aged  36,  was  admitted  to  the  Dundee  Eoyal  In- 
firmary on  4th  December  1905.  She  had  been  married 
eighteen   years,  and   has   had   nine  pregnancies,  the   last   five 


BY   DR   ELIZABETH   H.    B.    MACDONALD.  99 

years  ago.  The  first  two  pregnancies  resulted  in  miscarriage 
at  the  third  month,  the  third  was  normal,  the  fourth  was 
premature  (twins  at  the  sixth  month),  the  fifth  ended  in  a 
miscarriage  at  the  fifth  month,  the  three  following  were  normal, 
and  the  last  ended  in  a  miscarriage  at  the  fifth  month.  Menses 
began  at  14,  occurring  regularly  every  three  to  four  weeks, 
unaccompanied  by  pain.  She  had  some  trouble  which  she 
described  as  a  "  growth  of  the  womb "  after  the  seventh  preg- 
nancy, eight  years  ago,  but  this  disappeared  under  treatment  by 
"  douches  and  medicine."  Since  the  last  pregnancy  she  has  not 
felt  well,  and  for  more  than  a  year  has  had  severe  menstrual 
pain,  which  has  become  much  worse  during  the  last  two  or 
three  months.  The  pain  lasts  from  two  days  to  a  week,  beginning 
before  the  onset  of  the  discharge;  is  worst  for  two  or  three 
hours  after  the  onset,  and  continues  after  the  flow  ceases.  The 
pain  makes  her  sick.  The  discharge  is  normal  in  amount  and 
character,  and  there  is  no  intermenstrual  discharge.  She  suffers 
from  severe  headaches  and  occasional  frequency  of  micturition. 

On  admission,  she  was  found  to  be  thin  and  pale,  and  as  the 
physical  examination  gave  rise  to  the  suspicion  of  interstitial 
fibro-myoma  of  the  uterus,  hysterectomy  was  decided  on. 

Operation. — ProfessorKynoch  removed  the  enlarged  uterus  by 
the  vaginal  route.     The  patient  made  an  uninterrupted  recovery. 

Path.  No.  4559. — The  specimen  consists  of  the  uterus,  which 
is  generally  enlarged,  measuring,  after  hardening  in  alcohol,  10 J 
cm.  x  5  cm.  x  5  cm.  On  section,  the  uterine  walls  are  seen  to 
be  thickened,  and  the  endometrium  to  be  strikingly  thickened. 
The  uterine  cavity  is  8  cm.  long;  the  anterior  wall  at  its 
thickest  part  measures  2J  cm.,  and  the  posterior  2J  cm.  The 
mucous  membrane  shows  a  smooth  undulating  surface  of  a 
pinkish  colour,  and  is  of  normal  thickness  in  the  cervix,  greatly 
thickened  just  above  the  internal  os,  and  less  markedly 
thickened  towards  the  fundus ;  at  its  thickest  part  it  measures 
on  the  anterior  wall  7  to  8  mm.,  and  on  the  posterior  9  to  10  mm. 


100    HEMORRHAGE  AND  ARTERIOSCLEROSIS  OF  UTERINE  VESSELS, 

Histological  Examination :  Mucous  Membrane. — The  most 
marked  change  is  the  great  increase  in  the  number  of  the  glands, 
a  few  of  which  are  dilated.  The  glandular  epithelium  is 
swollen  and  oedematous.  The  stroma  is  loose  and  oedematous, 
and  the  vessels  show  marked  condensation  of  the  stroma 
around  them.  The  junction  between  mucosa  and  muscle  wall 
is  strikingly  irregular,  glands  penetrating  the  muscle  to  an 
unusual  depth,  and  carrying  with  them  strands  of  stroma 
(Kg.  1). 

Musculature. — The  proportions  of  muscular  and  fibrous 
tissue  appear  about  equal.  The  tissues  are  oedematous,  the 
muscle  nuclei  appearing  swollen,  and  patches  of  embryonic  cells 
are  seen  throughout  the  musculature  between  the  muscle 
bundles. 

Vessels. — The  larger  arteries  are  thickened  in  all  their  walls. 
The  lumen  is  irregular  in  many  cases,  from  projection  of  the 
media  and  occasionally  of  the  intima.  With  Weigert's  stain 
these  irregular  projections  of  the  intima  are  seen  to  contain  a  good 
deal  of  elastic  tissue,  and  the  thickened  inner  elastic  lamina  is 
well  shown,  as  also  the  deposition  of  elastic  tissue  in  and  around 
the  degenerated  adventitia.  The  intimal  thickenings  are  shown 
to  be  almost  entirely  fibrous  by  Van  Gieson's  stain,  and  the 
degenerated  areas  around  the  vessels  appear  bright  yellow. 
The  media  appears  rather  poor  in  nuclei,  and  the  degenerated 
areas  are  almost  free  of  nuclei,  in  a  hgematoxylin  preparation. 
The  "  periarterial "  degeneration  is  very  marked  is  some  parts, 
especially  in  the  smaller  vessels  near  the  endometrium  (Fig.  1). 
Some  of  the  arteries  show  a  remarkable  proliferation  of  the 
intima  causing  almost  complete  obliteration  of  the  lumen.  The 
veins  show  similar  changes.  There  is  an  irregular  proliferation 
of  the  inner  coat,  with  an  increase  in  fibrous  tissue,  and  a 
thickening  of  the  outer  coat  with  degeneration  extending  into 
the  surrounding  tissues — "perivenous"  degeneration  (Figs.  6 
and  7). 


BY    DR    ELIZABETH    II.    B.    MACDONALD. 


101 


The  case  is  of  interest  in  several  ways.  The  enormous 
hypertrophy  of  the  endometrium  in  the  absence  of  any  tendency 
to  haemorrhage,  and  the  marked  penetration  of  the  glands  into 
the  underlying  muscle  without  in  the  least  suggesting  a  malig- 
nant process,  are  evidences  that  the  primary  trouble  is  in  the 
endometrium.  Cornil  noted  this  penetration  of  the  glandular 
elements  as  characteristic  of  chronic  metritis.  The  cause  of 
the  pain  is  obscure.  Possibly  it  was  simply  an  exaggeration  of 
the  pain  commonly  experienced  at  the  height  of  menstrual 
congestion:  possibly  the  much  thickened  mucosa,  acting  as  a 
foreign  body,  induced  more  severe  contractions  than  normal 
in  the  endeavour  of  the  uterus  to  expel  the  foreign  body,  and 
the  increased  blood  pressure  from  ovarian  stimulation  in  the 
premenstrual  stage  started  the  contractions,  which  became  more 
severe  as  the  congestion  increased.  The  increase  in  the 
musculature  may  then  be  of  the  nature  of  a  true  "  work-hyper- 
trophy." The  existence  of  patches  of  embryonic  cells  throughout 
the  entire  muscle  wall,  but  most  commonly  in  its  inner  half,  is 
noticeable,  and  suggests  extension  of  an  infective  process  from 
the  endometrium.  Probably  the  case  is  to  be  classified  as  one 
of  chronic  metritis,  secondary  to  chronic  infective  endometritis, 
the  musculature  being  as  yet  but  slightly  affected  by  the 
infective  process. 


The  senile  changes  occurring  in  the  uterine  vessels  are 
illustrated  in  the  following  case : — 

Mrs  D.,  aged  51,  millworker,  was  admitted  to  the  Dundee 
Eoyal  Infirmary  on  7th  May  1906.  She  had  had  seven 
pregnancies,  all  normal,  the  last  twenty-one  years  ago.  Menses 
began  at  13,  and  occurred  regularly  every  twenty-eight  days, 
lasting  for  two  days,  the  discharge  being  scanty  and  accom- 
panied by  slight  pain ;  the  menopause  occurred  four  years  ago. 
For  two  years  there  has  been  a  white  discharge,  fairly  copious, 
and  lately  the  discharge  had  been  bloody  at  times.     She  had 


102    HEMORRHAGE  AND  ARTERIOSCLEROSIS  OF  UTERINE  VESSELS, 

been  in  the  Infirmary  in  the  beginning  of  1905,  with  symptoms 
of  mitral  incompetence,  some  chest  trouble  and  diarrhoea 
suggesting  enteritis,  and  again  in  February  1906,  with  gastro- 
intestinal symptoms. 

Physical  Examination. — Patient  is  a  worn-out  old  woman, 
and  was  intoxicated  on  admission.  She  has  a  slight  cough; 
there  are  dullness  and  tubular  breathing  without  accompani- 
ments at  the  left  apex.  There  is  a  soft  systolic  mitral  murmur. 
She  complains  of  frequency  of  micturition.  Examination  under 
chloroform  showed  the  cervix  to  be  much  shortened,  the 
vaginal  aspect  normal  except  for  small  submucous  haemorrhages. 
There  was  bleeding  from  the  orifice.  A  swelling,  possibly  the 
fundus,  was  felt  lying  to  the  left;  and,  suspecting  malignant 
disease  of  the  body  of  the  uterus,  Dr  Buist  decided  to  do 
vaginal  hysterectomy. 

Operation. — Dr  Buist  operated  on  18th  May.  An  incision 
was  made  in  the  posterior  fornix  and  into  the  pouch  of  Douglas. 
A  tumour  mass  was  found  on  the  left  side,  nodular,  and  not 
very  mobile.  The  right  broad  ligament  was  crushed  and 
divided,  and  the  fundus  brought  down,  when  the  uterus  was 
seen  to  be  small  and  senile,  but  otherwise  apparently  normal. 

The  tumour  mass  could  not  be  brought  down,  and  median 
cceliotomy  showed  it  to  be  in  the  sigmoid  flexure  of  the  colon 
with  the  left  uterine  appendages  adherent.  The  adhesions 
were  crushed  and  divided  and  the  hysterectomy  completed. 
The  sigmoid  tumour  was  isolated  by  Kenton's  clamps  and 
removed,  and  the  bowel  sutured  end  to  end. 

The  condition  of  the  patient  after  the  operation  was  never 
very  hopeful,  owing  to  the  chest  condition,  and  on  the  21st  an 
offensive  vaginal  discharge  set  in,  becoming  later  putrid  and 
black  in  colour,  and  death  occurred  on  the  22nd. 

Path.  No.  4750. — The  specimen  consists  of  the  uterus, 
which  is  normal  in  contour  but  smaller  than  usual,  measuring 
6  cm.  x  3J  cm.  x  2|  cm.     The  cervix  appears  normal  save  for  a 


BY   DR    ELIZABETH    H.    B.    MACDONALD.  103 

few  subepithelial  haemorrhages.  The  vessels  entering  the 
uterus  are  visibly  thickened  and  prominent,  and  on  section  of 
the  uterus  the  vessels  stand  out  very  distinctly  in  the  vascular 
zone  at  the  junction  of  the  middle  and  outer  thirds  of  the  wall. 
Within  this  zone,  extending  into  the  mucosa,  the  muscular  wall 
presents  a  curious,  firm,  homogeneous  appearance.  The  mucosa 
is  atrophied,  and  stained  with  blood  in  some  places;  its  limits 
cannot  be  distinguished  by  the  naked  eye.  The  uterine  wall 
measures  1J  cm.  in  thickness,  and  is  firm. 

Histological  Examination :  Mucous  Membrane. — This  is 
atrophied  to  a  considerable  extent,  the  glands  persisting  in 
groups  between  which  fibrous  tissue  strands  run  right  up  almost 
to  the  surface  epithelium.  In  many  parts  fibrous  strands  run 
along  under  the  epithelium.  The  persisting  glands  are  small, 
with  swollen  epithelial  cells.  There  is  considerable  extravasa- 
tion of  blood  into  the  mucosa,  while  here  and  there  red  blood 
corpuscles  may  be  seen  making  their  way  to  the  surface  between 
the  individual  cells  of  the  intact  surface  epithelium.  The  stroma 
is  dense  and  its  component  cells  are  swollen  and  cedematous ; 
fibrous  strands  invade  it  in  all  directions. 

Muscular  Wall. — The  muscle  is  everywhere  separated  up 
by  bands  of  fibrous  tissue.  The  muscle  shows  evidence  of 
degeneration  and  atrophy,  its  nuclei,  especially  near  the 
endometrial  surface,  being  swollen  and  degenerate-looking,  and 
occasionally  fragmented. 

Vessels. — The  vessels  occur  in  characteristic  groups,  with 
very  narrow  lumina  (some  appear  entirely  obliterated)  and  a 
wide  area  of  degeneration  surrounding  them  (Fig.  2).  These 
areas  are  so  extensive  that  neighbouring  areas  closely  approach 
each  other,  and  give  a  very  striking  appearance  to  the  stained 
section,  in  which  the  degenerated  tracts  are  readily  recognised 
by  the  naked  eye.  The  process  is  most  marked  in  the  middle 
third  of  the  muscular  wall  (the  homogeneous  area).  These 
areas  stain  darkly  with  Weigert's  stain,  although  no   definite 


104    HEMORRHAGE  AND  ARTERIOSCLEROSIS  OF  UTERINE  VESSELS, 

structure  can  be  made  out  in  them  (Fig.  3),  and  they  appear 
bright  yellow,  in  contrast  to  the  yellow  of  the  muscular  tissue, 
in  Van  Gieson  preparations,  with  an  occasional  remnant  of  red, 
fibrous  tissue,  persisting  in  the  midst  of  the  structureless  yellow 
mass  (Fig.  2).  The  larger  vessels  of  the  vascular  zone  show 
various  degrees  of  thickening  and  degeneration  of  their  walls. 
Many  show  calcification  commencing  between  the  intima  and 
the  media  (Fig.  8).  The  intima  is  not  particularly  affected 
throughout;  with  Weigert's  stain  it  shows  a  thickening  and 
breaking  up  of  the  internal  elastic  lamina.  There  are  irregular 
projections  into  the  lumen  in  many  cases,  but  these  appear  to 
be  due  mostly  to  an  irregular  proliferation  of  the  media,  over 
which  the  uniformly  thickened  intima  extends.  Both  media 
and  intima  are  degenerated,  nuclei  being  very  few  and  far  apart. 
The  adventitia  is  thickened  throughout,  and  the  degenerated 
areas  in  and  around  the  adventitia  stain  deeply  with  Weigert's 
elastic  stain.  The  increase  in  the  adventitia  appears  to  be  due 
chiefly  to  elastic  tissue,  with  which  the  media  also  is  spun 
through,  the  elastic  fibres  again  blending  into  a  definite  layer  at 
the  internal  elastic  lamina.  The  veins  show  similar  changes. 
There  is  an  increase  of  fibrous  tissue  in  the  inner  coat,  and  a 
marked  deposition  of  elastic  t\ssu>e  in  the  degenerated  outer  coat. 
There  was  thrombosis  of  a  branch  of  one  of  the  ovarian  arteries 
where  it  entered  the  uterus  at  the  broad  ligament  attachment — 
a  thombosis  evidently  of  ol^  ;  landing,  since  there  was  organisa- 
tion with  formation  of  new  vessels  in  the  midst  of  the  thrombus. 
The  senile  change  in  this  case  was  very  advanced  consider- 
ing the  age  of  the  patient,  but  the  fact  that  when  admitted  to 
hospital  she  was  in  a  state  of  intoxication,  throws  some  light 
on  the  cause  of  the  premature  senility.  From  the  histological 
examination,  the  case  appears  to  have  some  points  in  common 
with  those  cases  reported  as  "  apoplexia  uteri "  by  von  Kahlden 
and  others,  where  there  was  hemorrhagic  infiltration  of  the 
endometrium,  associated  with  sclerosis  of  the  uterine  arteries. 


6— 


Fig.  1. — Path.  No.  4559.  No  haemorrhage.  "Periarterial"  degeneration  in  small 
vessels  near  the  mucosa.  Note  also  the  unusually  deep  penetration  of  the  glands 
into  the  muscle,  and  the  cellular  infiltration  between  muscle  bundles.  Hsema- 
toxylin  and  eosin.    (x  50.) 


a,  a\,  Degenerate  areas  round  small  arteries, 
musculature. 


b,  Glands  penetrating 


[Inset,  pages  104-105, 


Fig.  2.— Path.  No.  4750.  Senile  case.  Extensive  "intramural"  and  "periarterial"  degene- 
ration in  vessels  near  the  mucosa,  with  marked  narrowing  of  lumina.  Van  Gieson.  The 
degenerated  areas  stand  out  in  sharp  contrast  to  the  surrounding  tissue,  which  is  exten- 
sively fibrous,    (x  65.) 

a,  a1,  Narrow  ring  of  fibrous  tissue,  remains  of  adventitia. 


Fig.  3. — Same  group  of  vessels  as  shown  in  previous  figure.  Weigert's  elastic  stain. 
Note  persistence  of  internal  elastic  lamina,  and  presence  of  elastic  tissue,  which 
appears  black,  in  area  corresponding  to  light  (yellow)  area  in  previous  figure,    (x  65.) 

a,  Inner  elastic  lamina. 


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BY   DR   ELIZABETH    H.    B.    MACDONALD.  105 

The  occurrence  of  the  leucorrhoea,  beginning  two  years  after 
the  menopause,  is  undoubtedly  to  be  associated  with  the  dis- 
turbed compensation  in  the  heart,  which  became  evident  about 
the  same  time.  Later,  the  venous  obstruction  resulting  from 
the  sigmoid  cancer  added  to  the  circulatory  disturbance  in  the 
uterus,  and  the  discharge  thereupon  became  haemorrhagic  and 
more  troublesome  and  persistent. 

It  is  evident,  therefore,  that  even  very  advanced  premature 
senile  change  in  the  uterine  vessels,  with  calcification  in  some 
of  the  arteries,  and  consequent  rigidity,  degeneration  of  vessels 
throughout  the  entire  uterine  wall,  along  with  marked  fibrosis 
of  both  musculature  and  endometrium,  are  all  insufficient  of 
themselves  to  cause  serious  haemorrhage,  even  in  the  presence 
of  an  incompetent  heart.  It  is  equally  evident  that  in  a  normal 
senile  uterus,  an  incompetent  heart  and  venous  obstruction 
such  as  would  arise  from  cancer  of  the  sigmoid  flexure  would 
not  necessarily  give  rise  to  any  uterine  symptoms.  The  local 
condition  determining  the  discharge  in  this  case  is  probably 
the  premature  degeneration  of  the  vessels,  diapedesis  through 
their  degenerated  and  "  toneless  "  walls,  in  presence  of  a  sluggish 
arterial  supply  on  the  one  hand,  and  venous  obstruction  on  the 
other,  being  unusually  easy.  Alcoholism  as  a  factor  in  bring- 
ing about  this  premature  decay  of  the  vessels  is  well  known, 
but  how  the  effect  is  produced  is  still  obscure.  The  absence  of 
the  periodic  menstrual  stimulation  in  this  case  sufficiently 
accounts  for  the  absence  of  sudden  severe  haemorrhages. 

Several  cases  have  been  reported  where  severe  uterine 
haemorrhage  was  associated  with  general  arterio-sclerosis. 
But  this  association  does  not  simplify  matters  at  all,  except 
so  far  as  to  make  it  probable  that  the  uterine  arterio-sclerosis 
found  was  of  a  similar  nature  to  the  general  change. 
Many  cases  of  general  arterio-sclerosis  never  show  uterine 
haemorrhage.     So  in  cases  of  bleeding  where  there  is  a  history 


106    HEMORRHAGE  AND  ARTERIO-SCLEROSIS    OF   UTERINE  VESSELS, 

of  syphilis  many  years  previously.  Syphilis  we  know  to  be 
one  of  the  most  common  causes  of  general  arterio-sclerosis. 
But  by  no  means  all  cases  of  syphilis  are  attended  by  uterine 
haemorrhage.  What  determines  the  occurrence  of  the  haemor- 
rhage in  some  cases  ? 

The  following  case  is  of  interest : — 

E.  M.,  aged  50,  unmarried,  was  admitted  to  the  Dundee 
Royal  Infirmary  on  30th  April  1906.  One  pregnancy  (twins, 
six  months)  twenty  years  ago,  since  which  time  she  has  been 
blind  (coloboma,  chronic  iritis,  cataract).  Menses  began  at  15, 
and  occurred  every  three  to  four  weeks,  lasting  seven  days. 
Irregular  bleeding  began  in  November  1903,  the  first  haemor- 
rhage lasting  seven  weeks,  unaccompanied  by  pain,  the  second 
coming  on  after  an  interval  of  five  weeks  and  lasting  for  four, 
and  the  third,  after  an  interval  of  six  weeks,  lasting  for  five 
weeks,  at  which  time  she  was  curetted,  the  curettings  showing 
nothing  noteworthy.  The  physical  examination  at  this  time 
showed  the  os  to  be  patulous,  edges  oedematous  and  slightly 
rough ;  the  fundus  was  nearly  3  inches  above  the  symphysis  ; 
there  was  slight  tenderness  in  the  left  iliac  region,  and  here  the 
left  tube  could  be  palpated  as  a  smooth,  fairly  firm,  elastic  oval 
swelling.  There  was  uterine  haemorrhage  on  manipulation. 
The  bleeding  recommenced  eleven  days  after  the  curettage,  and 
recurred  at  intervals  up  to  the  time  of  admission,  the  last 
haemorrhage  having  begun  two  months  before  admission,  and 
continued  up  to  that  time. 

Physical  Examination. — Patient  is  very  weak,  giddy,  and 
faint.  There  is  slight  pain  all  over  the  abdomen.  She  is  pale, 
with  dilated  capillaries  on  the  cheeks.  Pulse  104,  of  "water- 
hammer  "  variety ;  and  examination  of  the  heart  shows  presence 
of  aortic  systolic  and  diastolic  murmurs. 

Operation. — Hysterectomy  was  performed  by  Dr  Buist  a 
week  after  admission.     A  perivaginal  incision  was  made,  and 


BY   DK    ELIZABETH    H.    B.    MACDONALD  107 

a  roughly  "  banana-shaped "  hydrosalpinx  of  the  left  side 
removed,  clear  fluid  escaping.  The  left  ovary,  which  was 
slightly  cystic,  was  crushed  and  removed;  and  the  normal 
right  ovary  was  left.  The  patient  died  on  the  second  evening 
after  the  operation,  and  the  post-mortem  examination  showed 
widening  of  the  aorta,  with  some  atheroma;  the  kidneys  con- 
tracted and  unequal  in  size,  and  the  liver  fatty. 

Path.  No.  4738. — The  specimen  consists  of  the  uterus,  and 
the  cystic  left  tube.  When  inflated  the  tube  appears  roughly 
to  be  equal  in  size  and  similar  in  shape  to  a  banana,  with  an 
extremely  thin,  smooth,  transparent  wall. 

The  uterus  is  of  normal  contour,  but  generally  enlarged; 
the  serous  surface  is  smooth  and  free  from  adhesions.  The  lips 
of  the  cervix  are  somewhat  hypersemic  and  very  slightly 
nodular;  the  cervix  is  3 J  cm.  broad,  and  shows  a  transversely 
oval  aperture  measuring  1J  x  1  cm.  The  uterus  measures 
9 \  cm.  x  5 \  cm.  x  4 J  cm. ;  the  cavity  from  fundus  to  external 
os  measures  7J  cm. ;  in  breadth,  from  the  centre  of  the  canal 
outwards  in  the  direction  of  the  right  cornu,  it  measures  1J  cm., 
but  in  the  direction  of  the  left  cornu,  owing  to  the  hydrosal- 
pinx, is  reduced  to  f  cm.  The  muscle  appears  normal,  though 
very  pale,  and  the  blood-vessels  appear  distinctly  on  the  cut 
surface.  The  mucous  membrane  is  uniformly  smooth  and 
pale,  measuring  1  to  2  mm.  in  thickness  on  the  anterior  wall, 
which  itself  measures  2  J  cm. 

Histological  Examination :  Mucous  Membrane. — The  surface 
epithelium  is  intact  and  smooth  throughout  the  greater  part 
of  the  cavity;  towards  the  fundus  it  shows  a  tendency  to 
become  polypoid.  The  glands  are  not  increased  in  number,  but 
appear  larger  than  usual,  with  very  markedly  swollen  epithelial 
cells.  The  stroma  is  oedematous,  and  its  cells  swollen,  and 
many  large  dilated  blood  spaces  lined  by  a  single  layer  of 
endothelium  are  to  be  seen  just  beneath  the  surface  epithelium. 
The  thick-walled  capillaries  appear  normal  in  many  cases,  but 


108    HAEMORRHAGE  AND  ARTERIO- SCLEROSIS    OF   UTERINE  VESSELS, 

some  are  thickened  by  condensation  of  the  stroma  around 
them,  and  one  or  two  show  hyaline  degeneration  (Fig.  13). 
Vessels  having  definite  fibrous  and  muscular  walls  are  found 
within  the  mucosa,  occurring  often  quite  close  to  the  glands 
(Fig.  12),  and  in  sections  stained  by  Weigert's  stain  for  elastic 
fibres,  these  show  a  well-marked  inner  elastic  lamina. 

The  junction  between  mucosa  and  muscle  is  sharply 
marked,  and  here  the  number  of  dilated  lymphatic  spaces  and  the 
numerous  groups  of  vessels  with  thickened  walls  are  striking. 

Muscular  Wall. — The  muscle  appears  on  the  whole  well- 
preserved.  There  is  no  marked  increase  in  the  amount  of 
fibrous  tissue,  but  in  some  parts  the  fibrous  tissue  which 
throughout  the  specimen  penetrates  between  the  individual 
muscle  fibres,  appears  to  have  increased  and  produced  atrophy 
of  the  enclosed  muscle  fibres.  No  broad  bands  of  fibrous  tissue 
are  to  be  seen  in  the  specimen  except  such  as  form  the  adven- 
titial coats  of  the  larger  vessels.  The  fibrous  tissue  throughout 
shows  a  tendency  to  degenerate. 

Vessels. — The  larger  vessels  in  the  vascular  zone  show  a 
marked  thickening  of  all  their  coats.  In  the  arteries,  the 
intima,  as  a  rule,  is  irregularly  thickened,  forming  definite  pro- 
jections into  the  lumen  in  some  cases.  In  sections  stained  by 
haematoxylin  and  eosin,  the  thickened  intima  is  seen  to  be  poor 
in  nuclei  and  more  or  less  degenerated ;  with  Van  Gieson's 
stain  there  appears  a  considerable  increase  in  fibrous  tissue 
which  is  markedly  degenerated;  while  Weigert's  elastic 
stain  shows  a  definite  increase  in  elastic  fibres  throughout  the 
intima  in  many  of  the  larger  arteries.  This  is  strikingly  seen 
in  a  branch  of  the  uterine  artery  at  its  point  of  entrance  to  the 
uterine  wall  (Fig.  14).  The  media  also  in  this  vessel  is  greatly 
thickened,  and  while  the  muscle  nuclei  are  fairly  well  pre- 
served, as  seen  in  a  haematoxylin  preparation,  there  are  signs 
of  atrophy  of  the  muscle  in  parts.  The  muscle  fibres  are  seen, 
in  a   Van    Gieson    preparation,    to    be  interpenetrated  by    i 


BY    DR    ELIZABETH    II.    B.    MACDONALD.  109 

degenerating  fibrous  tissue,  which  apparently  presses  on 
and  destroys  the  muscle  cells.  This  is  also  to  be  seen  in 
the  arteries  within  the  uterine  wall,  though  to  a  much  less 
extent;  the  usual  condition  is  a  hypertrophy  of  the  media 
without  evident  degeneration.  The  adventitia  is  thickened 
and  degenerated  in  the  larger  arteries,  appearing  in  Van  Gieson 
sections  as  a  grandular  red  or  pink  mass,  and  not  taking 
Weigert's  stain.  The  veins  do  not  show  much  change  from 
the  normal.  In  some  cases  both  coats  are  thickened,  the  inner 
showing  irregular  proliferation  filling  up  the  lumen,  and  the 
outer  showing  an  increase  in  elastic  tissue,  which  also  extends 
in  fine  fibrils  through  the  inner  coat.  The  smaller  arteries 
show  swelling  of  the  endothelial  cells  as  a  rule,  or  slight 
irregular  proliferation  of  the  intima ;  slight  thickening  of  the 
media ;  and  marked  thickening  in  the  adventitia  (Figs.  9  and 
10).  The  groups  of  vessels  so  affected  occurring  amongst  the 
glandular  tissue  at  the  junction  of  mucosa  and  muscle  are 
particularly  striking  (Fig.  11). 

Cervix. — There  is  a  cystic  condition  of  some  of  the  glands, 
and  here  and  there  a  subepithelial  hemorrhagic  infiltration. 
The  vessels  are  slightly  thickened  in  all  their  coats,  but  there  is 
no  marked  increase  in  the  elastic  tissue.  The  arteries  retain 
their  well-marked  internal  elastic  lamina,  which  appears 
thickened  only  in  one  or  two  of  the  larger  vessels. 

It  is  noticeable  that  in  this  case  there  is  no  typical 
"periarterial"  or  "perivenous"  degeneration.  The  degenera- 
tion here  is  in  the  fibrous  tissue  of  the  thickened  adventitial 
coats,  the  degenerated  areas  looking  pink  and  granular  with 
Van  Gieson's  stain,  and  not  staining  at  all  with  Weigert's. 
So  far,  it  might  appear  that  there  is  a  failure  in  the  normal 
increase  in  elastic  tissue.  But,  on  the  other  hand,  there  is,  in 
the  larger  vessels  particularly,  a  definite  increase  in  elastic 
tissue  in  the  intima;  and  the  uterus  in  this  case  had  been 
only  once  pregnant.     The  possibility  of  infection  must  not  be 


110   HEMORRHAGE  AND  ARTERIOSCLEROSIS  OF  UTERINE  VESSELS, 

overlooked,  since  there  was  evidence  of  adnexal  inflammation. 
Addinsell  describes  degeneration  of  the  fibrous  tissue  as  the  third 
stage  of  the  pathological  process  in  "  chronic  infective  metritis." 

Certainly  failure  of  increase  in  the  elastic  tissue  will  not 
explain  the  haemorrhage  in  another  case  examined,  that  of  a 
woman,  aged  45,  with  a  history  of  severe  monorrhagia  for  ten 
years,  and  in  whom  death  suddenly  occurred  three  months 
after  curetting,  from  septic  peritonitis,  evidently  originating 
from  an  acute  endometritis  (Path.  No.  2505).  The  vessels 
show  marked  and  extensive  degeneration  within  and  around 
their  walls  (Fig  4).  The  intima  is  not  markedly  affected,  but 
the  media  in  most  of  the  larger  arteries  is  very  greatly  thickened 
and  degenerated ;  and  in  the  most  advanced  cases  both  media 
and  adventitia  are  represented  in  Weigert  sections  as  solid 
clumps  of  elastic  tissue  (Fig.  5).  The  veins  have  thickened 
inner  coats  of  well-formed  fibrous  tissue,  and  show  an  increase 
in  elastic  tissue  in  their  outer  coats,  in  the  position  occupied 
by  degenerated  areas  of  few  nuclei  in  hematoxylin  and  eosin 
preparations.  The  vessel  condition  is  practically  identical  with 
that  found  in  the  senile  case  already  described,  although  the 
changes  have  not  extended  to  the  smaller  vessels  to  the  same 
extent.  The  musculature  in  this  case  is  separated  up  by  bands 
of  fibrous  tissue,  which  is  well  formed  and  not  degenerated. 
The  cause  of  the  menorrhagia  is  not  evident. 

Is  there,  then,  an  arterio-sclerosis  of  the  uterine  vessels 
apart  from  that  brought  about  by  physiological  causes  ?  If  so, 
will  the  condition  necessarily  be  accompanied  by  hemorrhage  ? 

If  we  consider  how  the  physiological  changes  are  brought 
about,  the  question  becomes  clearer.  Westphalen  and  Thoma 
have  endeavoured  to  show  that  the  peculiar  vessel  changes  in 
the  uterus  are  essentially  due  to  the  changes  in  blood  pressure 
to  which  the  functionally  active  uterus  is  subject.  The  periodic 
increase  in  blood  pressure  at  the  menstrual  periods,  and  still 
more   the    pressure   changes   incident   to   pregnancy  and    thfl 


BY   DR   ELIZABETH   H.    B.    MACDONALD.  Ill 

puerperium,  cause  changes  in  the  uterine  vessels  to  which  no 
other  vessels  in  the  body  are  subject  to  the  same  extent.  The 
uterine  vessels  are,  so  to  speak,  shorter-lived  than  any  others. 
If,  now,  it  be  supposed  that  changes  in  blood  pressure  in  these 
arteries  arise  from  some  pathological  condition,  apart  from 
pregnancy,  etc.,  similar  changes  will  presumably  occur. 

Theoretically,  we  may  suppose  that  persistent  high  tension 
in  the  uterine  and  ovarian  arteries  will  bring  about  as  a  first 
result,  through  increased  vasomotor  stimulation,  an  exaggerated 
response  on  the  part  of  the  musculature,  so  that  a  true  "  work- 
hypertrophy"  takes  place,  i.e.,  hypertrophy  of  the  uterine 
muscle  generally,  including  the  muscular  coats  of  the  arteries. 
Since  arteries  acquire  their  coats  in  proportion  to  the  pressure 
they  are  called  on  to  resist,  it  is  probable  that  the  adventitia 
will  be  strengthened  by  an  increase  in  fibrous  tissue.  The 
strain  must  necessarily  tell  on  the  intima.  In  all  parous  uteri 
the  inner  elastic  lamina  of  the  arteries  is  thickened.  In  the  case 
described,  where  general  arterio-sclerosis  was  present,  the 
larger  arteries  showed  a  marked  increase  in  elastic  tissue  in  the 
intimal  coats.  Probably  this  is  the  nature  of  the  compensatory 
change  when  the  artery  wall  is  subjected  to  a  sustained  increase 
in  blood  pressure.  Later  the  continued  pressure  will  bring 
about  degenerative  changes ;  in  the  intima,  whose  nuclei  dis- 
appear to  a  great  extent;  and  in  the  media,  where  fatty 
degeneration  and  atrophy  of  the  muscle  may  occur.  We  may 
further  suppose  that  if  the  increase  in  pressure  be  gradual  and 
sustained,  as  would  occur  in  a  case  associated  with  general 
arterio-sclerosis,  the  compensatory  change  will  extend  gradually 
to  smaller  and  smaller  branches  of  the  vessels,  reaching  eventu- 
ally the  endometrial  capillaries.  When  degenerative  changes 
have  occurred,  and  the  vessels  can  no  longer  react  to  the 
increased  blood  pressure,  in  other  words,  when  compensation 
is  disturbed,  haemorrhage  will  result.  The  importance  of 
menstruation  in  starting  the  haemorrhage  has  already  been  seen. 


112    HEMORRHAGE  AND  ARTERIO- SCLEROSIS  OF  UTERINE  VESSELS, 

All  these  changes  are  illustrated  in  the  case  described 
above,  in  which  there  was  general  arterio-sclerosis,  and  a  fairly 
clear  history  of  syphilitic  infection  dating  back  twenty  years. 
The  peculiar  pathological  features  in  the  case  are — (1)  the 
very  distinct  affection  of  the  intima,  which  showed  irregular 
proliferation  and  an  increase  in  wavy  elastic  fibres  out  of  all 
proportion  to  the  general  elastic  increase,  whixm  was  only  very 
slightly  marked,  throughout  the  uterus ;  (2)  the  marked  fibrosis 
around  the  vessels,  particularly  the  smaller  vessels,  unassoci- 
ated  with  fibrosis  of  the  uterus  generally ;  (3)  the  occurrence 
of  groups  of  thickened  vessels  at  the  junction  of  mucosa  and 
muscle,  and  the  tendency  of  these  vessels  to  invade  the  mucosa ; 
(4)  the  existence  of  vessels  with  definite  walls  and  a  well- 
marked  internal  elastic  lamina  within  the  mucosa,  and  thicken- 
ing and  degeneration  of  the  "  thick-walled "  endometrial 
capillaries. 

The  case  is  clearly  one  of  uterine  arterio-sclerosis  associated 
with  general  arterio-sclerosis.  A  clear  case  of  pathological 
uterine  arterio-sclerosis  existing  as  a  purely  local  condition  has 
yet  to  be  demonstrated. 

The  changes  in  the  vessels  due  to  physiological  processes 
cannot  be  regarded  as  causes  of  haemorrhage.  They  may  go  to 
an  extreme  degree  without  the  occurrence  of  any  abnormal 
bleeding.  This  is  only  natural.  Further,  since  these  changes 
are  essentially  brought  about  by  the  changes  in  blood  pressure 
associated  with  the  functionally  active  uterus,  they  are  possibly 
indistinguishable  from  changes  due  to  a  pathological  increase 
in  blood  pressure.  In  the  causation  of  haemorrhage,  the  import- 
ant thing  is  the  pathological  increase  in  blood  pressure  which 
gives  rise  to  the  vessel  condition.  To  speak  of  the  arterio- 
sclerosis as  the  cause  of  the  haemorrhage  is  a  mere  confounding 
of  words.  The  haemorrhage  is  a  symptom  of  the  condition  of 
which  the  arterio-sclerosis  is  a  sign.  The  association  between 
hyperpiesis  and  arterio-sclerosis  in  other  parts  of  the  body  is 


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Fig.  8.— Path.  No.  4750.    Senile  case.    Calcareous  degeneration  beginning  in 
superficial  layers  of  media  in  large  artery,     (x  30.) 

a,  Intima.    b.  Media,    c,  Calcifying  area. 


"Ssai 


S.S-S 

'.  g  <D  1  «  x 
a 


Fig.  11.— Same  case  as  Figs.  9  and  10.    Group  of  thickened  vessels  occurring 
just  under  the  mucous  membrane.    (  x  90.) 

a,  Mucosa,    a1,  Detached  glandular  epithelium,    b,  Muscle. 


Fig.  12. — Same  case  as  above.     Weigert.    Small  vessels  with  definite  walls  and  well-marked^ 
internal  elastic  laminse  occurring  within  the  endometrium.    ( x  200.) 

a,  a1,  Unstained  glandular  epithelium,    b,  Unstained  stroma  of  mucosa, 
c,  c1,  Inner  elastic  lamina. 


Fig.  13.— Same  case  as  above     "  Hyaline  "  degeneration  of  an  endometrial  capillary. 
Note  the  circular  arrangement;  of  the  stroma  round  the  vessel.    (  x  230.) 


Fig.  14.— Same  case  as  above.    Irregular  proliferation  of  intima  in  a  branch  of 
uterine  artery  where  it  enters  the  uterus.   .  Hematoxylin  and  eosin. 

a,  Intima.    b,  Media,    c,  Adventitia. 


U  c3 


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BY   DR   ELIZABETH   H.    B.    MACDONALD.  113 

well  known  though  not  clearly  understood.  It  seems  clear  in 
some  cases  that  the  increased  blood  pressure  precedes  the 
change  in  the  vessels  and  is  the  cause  of  it,  although  the  case 
is  complicated  by  the  fact  that  the  vessel  change  may  itself 
induce  a  rise  in  blood  pressure  by  increasing  the  peripheral 
resistance.  The  real  difficulty  is  that  the  aetiology  of  arterio- 
sclerosis occurring  anywhere  in  the  body  is  still  obscure. 
After  all  the  well-established  causes,  including  syphilis, 
alcoholism,  various  forms  of  poisoning,  etc.,  have  been  excluded, 
there  remains  a  class  of  unexplained  cases  arising  independently 
of  these  causes  in  comparatively  young  people,  and  associated 
in  some  way  with  an  increased  arterial  tension.  Similar  con- 
ditions may  arise  in  the  uterus,  possibly  associated  with  some 
form  of  local  toxaemia.  But  the  essential  point  is  the  condition 
behind  the  vessel  change.  It  is  readily  conceivable  that  if  an 
increase  in  arterial  pressure  occurred  suddenly,  or  occurred  in  a 
uterus  of  deficient  musculature,  haemorrhage  of  a  severe  kind 
might  occur  before  any  marked  changes  in  the  vessels  had  had 
time  to  occur.  Thus  Simmonds'  case  of  uncontrollable  haemor- 
rhage showed  a  sclerosis  of  the  uterine  artery  alone.  At  the 
opposite  extreme  are  those  cases  where  the  changes  have 
extended  to  the  vessels  of  the  endometrium,  and  where  the 
diagnosis  can  be  made  from  curettings. 

Eeferences. 

1.  Addinsell  (A.  W.). — "  Chronic  Infective  Metritis,"  Journ. 

Obst.  and  Gyn.  Brit.  Empire,  July  1906,  vol.  x.,  No.  1. 

2.  Anspach   (B.    M.). — "Metrorrhagia    Myopathica,"    Amer. 

Journ.  Obst.,  Jan.  1906. 

3.  Bandler. — "  The  Ovary :  its  Eelations  to  Normal  Functions 

and  to  Pathological  States,"  Med.  Record,  1901,  p.  405. 

4.  Barbour  (A.  H.  R). — "Climacteric  Haemorrhage  due   to 

Sclerosis,  etc.,"  Obst.  Trans.  Edin.,  vol.  xxx.,  p.  71. 

H 


114     HEMORRHAGE  AND  ARTERIOSCLEROSIS  OF  UTERINE  VESSELS, 

5.  Bland-Sutton. — Brit.  Med.  Journ.,  1899,  vol.  i.,  p.  840. 

"Fibrosis  of  Uterus,"  Brit.  Med.  Journ.,  1904,  vol. 

ii.,  p.  1072. 

"  100  Hysterectomies,  etc.,"  Lancet,  27th  May  1905, 


p.  1406. 

6.  Boldt  (J.  H.). — "  Cavernous  Angioma  of  Uterus,"  Amer. 

Journ.  Obst.,  Sept.  1893. 

7.  Berissoff   (A.). — "Ueber    die   Veranderung   der   Uterus- 

schleimhaut  bei  Fibromyomen  in  Zusammenhange  mit 
Uterusblutungen,"  Monats.  fur  Geb.  und  Gyn.,  vol.  ii., 
pt.  5,  p.  351. 

8.  Brennecke. — "Zur  Etiologie   der   Endometritis   fungosa," 

Archivfilr  Gyn.,  1884,  vol.  ii.,  p.  455. 

9.  Brionde. — "De  la  sclerose  de  l'uterus,"  La  Gyn.,  1896,  vol.  i. 

10.  Cholmogoroff. — "Sklerose   der    Uterusarterien,"    Monats. 

fur  Geb.  und  Gyn.,  vol.  ii.,  p.  692. 

11.  Cornil. — "Lecons    sur   l'anat.    pathol.  des   metrites,   etc." 

Paris,  1889. 

12.  Dickinson   (R   L.). — "The   Intractable    Menorrhagias   of 

Arterio-sclerosis  of  the  Uterus,"  Brooklyn  Med.  Journ., 
Feb.  1906,  vol.  xx„  No.  2. 

13.  DolfIris  (J.  A). — "Troubles  ut6rins  d'origine  degenerative," 

La  Gyn.,  April  1901  and  June  1901. 

14.  Dunning  (L.   H.). — "Acute  Senile   Endometritis,"   Journ. 

Amer.  Med.  Associa.,  3rd  Nov.  1901. 

15.  Findley  (Palmer). — "Arterio-sclerosis  of  Uterus,"   Amer. 

Journ.  Obstet,  1901,  vol.  i.,  p.  30. 

"  Arterio-sclerosis  of  the  Uterus  as  a  Causal  Factor 

in  Uterine  Hemorrhage,"  Amer.  Journ.  Obstet.,  July 
1905,  p.  71. 

16.  Freund. — "  Zur  Lehre  v.  d.  Blutgefassen  der  normalen  und 

kranken  Gebarmutter."     Jena,  1904. 

17.  Gardner  and  Goodall. — "Chronic  Metritis  and  Arterio- 

sclerotic Uteri,"  Brit.  Med.  Journ.,  3rd  Nov.  1906. 


BY   DR   ELIZABETH   H.    B.    MACDONALD.  115 

18.  Gottschalk. — "Eine  besondere  Art.    seniler,  hamorrhagi- 

scher,  leukocy  tarer  Hyperplasie  der  Gebarmutterschleim- 
haut,"  Archivfilr  Gyn,,  vol.  lxvi.,  1902,  p.  169. 

19.  Grube. — "Ueber    unstillbare    Uterusblutungen    und   Art. 

Sklerose,  etc.,"  Centralbl  fur  Gyn.,  1902,  p.  673. 

20.  v.  Kahlden. — "Ueber  die   sogenannte  Apoplexia   Uteri," 

Ziegler's  Beitr.,  1898,  vol.  xxiii.,  p.  161. 

21.  Ketffer. — "  Histology  of  the  Nervous  System  in  the  Uterus," 

Bull,  de  la  Soc.  Beige  de  Gyn.  el  d'Obst.,  vol.  xi.,  No.  5. 

22.  Klob.  —  "  Pathol.    Anat.   der  weiblichen    Sexual-organen," 

p.  173. 

23.  Kustner. — "  Die  Behandlung  der  post-partum  Blutungen," 

Deut.  med.  Woch.,  1890,  p.  5. 

24.  Lofqvist. — "Zur   Pathologie   der   Mucosa  corporis  uteri." 

Berlin,  1903. 

25.  Macgregor  (Jessie  M.). — " Pathology  of  the  Endometrium," 

1905. 
2G.  Marchesk— Arch.  d'Obst.  et  Gyn.,  1897. 

27.  Martin. — Path,  und  Therapie  der  Frauenkrankheiten,  vol.  i., 

p.  994. 

28.  Meerdervoort  (Pompe  v.). — "Anatomie    de    la   Pseudo- 

endometrite,"  Bevue  de  Gyn,,  1902,  vol.  vi.,  p.  227. 

29.  Melnikow-Kaswendenkow.  —  Zieglers    Beitr.    zur   path. 

Anat.  und  allgem.  Pathol.,  vol.  xxvi. 

30.  Mullerheim.— "Arterioskleros.  Uter.,"  Zeits.  filr  Geb.  und 

Gyn.,  vol.  xxxvi.,  p.  355. 

31.  Pichevin  et  Petit. — "  Metrorrhagies  et  lesions  vasculaires 

de  Puterus,"  Gaz.  Med.  de  Paris,  1895,  p.  553. 

32.  Pick. —  Volkmann's  Sammhmg  Minischer  Vortrage,  Nr.  283. 

33.  Pierra. — "  Primary  Uterine  Congestion  in  neuro-arthritic 

Patients,"  La  Gyn.,  June  1904. 

34.  Pozzi  et  Latteux. — "Sur  une  forme  rare  de  nitrite 
hemorrhagique,"  Revue  de  Gyn.,  1889,  vol.  iii.,  p. 
771. 


116    HEMORRHAGE  AND  ARTERIO-SCLEROSIS  OF   UTERINE   VESSELS, 

35.  Eeinecke.  —  "  Die   Sklerose   der   Uterinarterien   unci   die 

klimakt.    Blutungen,"   Archiv  fur    Gyn.,    vol.    liii.,  p. 
313. 

36.  Richelot  et  Bakozzi. — "  Scleros.  uter.  et  la  vrai  metrite," 

La  Gyn.,  Paris,  1901.  . 

37.  Saville.—  Brit.  Med.  Journ.,  1896,  vol.  ii.,  p.  713. 

38.  Shaw  (W.  F.).— "  Chronic  Metritis :  its  Pathology  and  its 

Relation  to  Chronic  Endometritis,"  Thesis,  Manchester, 
1906. 

39.  Simmonds. — "Ueber  Hamorrh.  d.  Endometr.  bei  Sklerose 

der  Uterus-arterien,"  Centralbl.  filr  Gyn.,  1901,  No.    3, 
p.  81. 

40.  Siredey  (A.). — "La  metrite  parenchymateuse  chronique," 

La  Gyn.,  Feb.  1902,  p.  1. 

41.  Theilhaber. — "Die     Ursachen    der     praklimakterischen 

Blutungen,"  Archiv  filr  Gyn,  1901,  vol.  lxii. 

und  Meier. — "  Die  Variationen,  im  Bau  des  Mesome- 

trium,  etc.,"  Archiv  filr  Gyn.,  1902,  vol.  lxvi. 

"Die   sogenannte  chronische  Metritis,  etc.,"   Archiv 


filr  Gyn.,  1903,  vol.  lxx. 

42.  Westphalen. — "  Zur  Physiologie  der  Menstruation,"  Archiv 

filr  Gyn.,  vol.  Hi.,  p.  35. 

43.  Wittek  (Kurt). — "  Die  sklerotischen  Gefassveranderungen 

des  Uterus,  etc.,"  Monats.  filr  Geburts.  und  Gyn.,  1906, 
vol.  xxiii,  p.  796. 


The  President  conveyed  to  Dr  Macdonald  the  thanks  of  the 
Society  for  bringing  this  piece  of  work  before  them.  Her  paper 
was  a  most  thorough,  a  most  scientific,  a  most  academic  dis- 
cussion of  the  subject.  It  was  a  difficult  subject,  and  Dr 
Macdonald  had  tackled  it  in  a  thoroughly  scientific  way.  It  was 
also  a  difficult  paper  for  them  to  discuss,  because  the  questions 
raised  in  it  were,  many  of  them,  novel  and  somewhat  complex. 


BY   DR   ELIZABETH   H.    B.   MACDONALD.  117 

It  seemed  to  him  that,  apart  from  the  purely  scientific  way  of 
presentation,  the  practical  view  came  to  be  that  the  uterus  at 
the  menopause  became  very  rapidly  old;  that  the  uterus,  so 
to  say,  might  be  70  while  the  patient  herself  was  still  between 
40  and  50;  and  that  in  the  ageing  of  the  organ  the  vessels 
might  become  old  before  the  rest  of  the  uterus.  It  occurred 
to  him  that  it  might  be  found  that  the  same  sort  of  changes 
occurred  in  the  placenta  in  cases  of  accidental  haemorrhage 
where  there  was  no  traumatism.  It  would  be  a  very  good  sup- 
plement to  her  work  to  compare  this  condition  in  the  uterus 
with  a  placenta  of  that  kind.  He  himself  thought  that  in 
looking  over  these  microphotographs,  he  had  seen  sections  of 
placentae  that  closely  resembled  them. 

Dr  Haultain  seconded  the  President's  eulogy  on  the  very 
excellent  paper  which  Dr  Macdonald  had  given  them.  The 
subject  was  very  wide,  and  one  they  could  not  discuss  in  its 
entirety.  There  were  one  or  two  important  practical  points 
which  had  been  brought  before  them.  In  the  first  place,  there 
could  be  no  doubt  that  haemorrhages  from  the  uterus  might 
be  threefold — endometric,  ovarian,  and  from  the  uterine  wall. 
The  endometric  variety,  which  they  all  knew  so  well,  with  the 
capillary  changes  and  so  on,  and  which  naturally  could  be  cured 
in  the  majority  of  cases  by  curetting.  It  was  perhaps  with  the 
other  two  varieties  that  the  paper  dealt  more  particularly. 
With  regard  to  the  ovarian  variety,  there  was  no  reasonable 
doubt  that  the  ovary  had  a  strong  influence  on  uterine  haemor- 
rhage. From  time  to  time  they  met  with  cases  in  which  the 
ovary  and  it  alone  was  the  cause  of  uterine  haemorrhage.  Some 
years  ago,  before  hysterectomy  was  such  a  common  operation, 
the  removal  of  the  ovaries  was  undertaken  for  severe  intractable 
cases  of  haemorrhage  for  which  curetting  would  not  do  any 
good.  It  struck  me  that  in  several  cases  bleeding  still  continued 
after  the  removal  of  the  ovaries ;  although  in  the  majority  of 
cases  monorrhagia  and  metrorrhagia  frequently  were  cured  by 


118   HAEMORRHAGE  AND  ARTERIOSCLEROSIS  OF  UTERINE  VESSELS, 

the  removal  of  the  ovaries,  which  made  it  certain  that  there 
was  an  important  ovarian  influence.  But  it  was  in  these  cases 
where,  after  the  removal  of  the  ovaries  the  bleeding  continued, 
in  which  there  was  some  condition  in  the  uterine  wall,  or  the 
vessels  penetrating  that  wall,  which  gave  rise  to  the  condition. 
He  had  had  upon  five  occasions  to  remove  uteri  for  that  condition, 
where  there  was  no  malignancy,  where  the  ovarian  condition, 
as  far  as  one  could  see,  was  perfectly  normal,  but  where  in 
spite  of  persistent  curetting,  and  in  one  case  in  spite  of  the 
removal  of  the  ovaries,  the  bleeding  had  continued.  Three  of 
these  cases  were  in  young  women  under  25.  In  the  other 
two  cases  the  women  were  well  past  the  menopause.  The 
condition  found  in  four  of  these  was  almost  identical — a 
very  considerable  arterio- sclerosis,  and  in  three  of  these  very 
considerable  thickening  of  the  uterine  wall,  analogous  to  that 
found  in  so-called  fibroid  and  in  subinvolution.  Further,  in 
making  some  investigations  in  fibroids,  one  found  in  a  consider- 
able proportion  of  fibroid  uteri,  that  this  condition  of  the  blood- 
vessels existed.  It  seemed  to  him  that  possibly  this  accounted 
for  those  cases  where,  after  the  removal  of  the  ovaries,  there  was 
still  bleeding  from  a  fibroid  uterus.  Post-climacteric  haemorrhage 
could  go  on  in  a  uterus  already  afflicted  with  fibroid  disease. 
There  was  certainly  a  class  of  case  where  nothing  but  removal 
of  the  uterus  could  cure  the  condition,  which  might  be  not 
only  post-climacteric,  but  might  occur  in  a  very  young  woman. 
And  it  seemed  to  him  a  far  better  operation  in  young  women 
in  whom  curetting  did  not  cure  the  condition,  and  where  the 
patients  were  invalided,  to  remove  the  uterus  and  leave  the 
ovaries,  than  to  remove  the  ovaries  and  leave  the  uterus; 
because  in  the  former  cases  the  ovarian  influence  was  not 
removed,  and  the  removal  of  the  uterus  itself  did  not  seem  to 
act  in  the  same  way  as  removal  of  the  ovaries,  for  it  was  an 
organ  which  did  not  appear  to  have  an  internal  secretion. 

Dr  Ritchie  said  he  had  listened  with  very  great  interest  to 


BY   DR   ELIZABETH   H.    B.    MACDONALD.  119 

the  paper.  Dr  Macdonald's  opinion  seemed  to  him  to  be  that 
the  arterio-sclerosis  was  practically  a  physiological  change  in 
aged  uteri,  and  that  haemorrhage  did  not  arise  quite  so  much 
from  changes  in  the  vessels  as  from  what  was  behind  them. 
He  asked  Dr  Macdonald  to  state  in  her  reply  whether  this  was 
the  opinion  which  she  advocated. 

Dr  B.  P.  Watson  said  he  could  not  offer  the  explanation  Dr 
Fordyce  desired.  As  to  the  particular  uterus  which  Dr  Barbour 
had  described  and  which  he  had  had  the  pleasure  of  examining, 
the  vessel  changes  in  it  were  very  much  the  same  as  Dr  Mac- 
donald had  described.  The  vessels  of  the  mucous  membrane 
were  specially  affected,  and  showed  great  thickening  of  the  walls 
and  hyaline  degeneration.  There  was  no  arterio-sclerosis  of 
any  other  vessels,  and  no  history  of  any  cause  likely  to  produce 
the  condition.  One  ovary  was  cystic,  but  no  other  abnormality 
was  present.  He  said  the  paper  had  been  a  most  interesting 
one,  and  the  microphotographs  shown  were  very  clear,  so  that 
he  would  have  liked  to  have  seen  the  actual  sections,  which 
must  be  very  fine. 

Dr  Porter  said  he  was  not  competent  to  discuss  the  paper, 
but  expressed  his  pleasure  at  having  heard  it  read.  He 
inquired  whether  there  was  any  history  of  haemophilia  in  any 
of  the  cases. 

Dr  Elizabeth  Macdonald,  in  reply,  thanked  the  Fellows  for 
the  way  in  which  they  had  received  the  paper.  In  reply  to  Dr 
Eitchie,  she  said  she  did  take  up  the  attitude  that  the  vessel 
changes  were  of  secondary  importance  in  the  causation  of 
haemorrhage.  She  had  come  to  this  conclusion  from  a  con- 
sideration of  the  case  of  premature  senile  change,  where  the 
vessels  were  extensively  degenerated,  and  where  there  was  no 
haemorrhage  to  speak  of.  As  to  septic  infection  causing  the 
vessel  changes,  there  was  no  doubt  that  it  was  one  of  the  most 
general  causes  of  vessel  degeneration.  But  in  the  case  quoted 
the  patient  had  suffered  from  monorrhagia  for  ten  years,  and 


120  EXHIBITION   OF   SPECIMENS,   ETC. 

the  infection  had  been  quite  a  recent  one,  not  lasting  for  more 
than  three  months,  so  that  it  could  not  in  this  case  explain 
the  monorrhagia  of  twenty  years'  standing. 


Meeting  IV. — February  9,  1907. 
Dr  J.  W.  Ballantyne,  President,  in  the  Chair. 

I.  The  following  ladies  and  gentlemen  were  elected  Ordinary 
Fellows  of  the  Society:— Mary  C.  Hamilton,  L.R.C.P.  &  S.E., 
L.F.P.S.  Glas.,  Sick  Children's  Hospital,  Edinburgh ;  Elsie  M. 
Barnetson,  M.B.,  Ch.B.,  31  Morton  Street,  Joppa ;  J.  A.  MacLeod, 
M.B.,  Ch.B.,  Royal  Maternity  Hospital,  Edinburgh ;  H.  S.  Reid, 
M.B.,  Ch.B.,  Royal  Maternity  Hospital,  Edinburgh. 

II.  The  President  showed — (a)  A  PAIR  OF  cystic  kidneys 
from  a  foetus.  There  had  been  some  difficulty  with  the  labour, 
and  the  child  was  still-born.  Only  a  very  rapid  post-mortem 
examination  was  permitted,  and  the  liver  and  both  kidneys  were 
found  to  be  enlarged.  The  kidneys  only  were  removed;  each 
weighed  over  4  ounces,  and  one  was  10  cm.  long  and  the  other 
9 \  cm. — about  three  times  the  normal  size.  There  was  not  very 
much  to  be  made  out  on  naked-eye  examination,  save  a  general 
spongy  appearance,  but  under  the  microscope  the  kidney  tissue 
was  seen  to  consist  of  hundreds  of  thousands  of  small  cystic 
cavities.  These  kidneys  are  supposed  to  be  not  really  cystic, 
but  a  form  of  adenomatous  degeneration,  and  so  are  really  to  be 
classed  as  tumours  rather  than  cystic  degenerations,  (b)  Frozen 
sections  of  A  female  fcetus,  born  in  Maternity  last  September. 
At  birth  it  was  thought  to  be  normal,  but  when  Dr  Ballantyne 
was  going  round  the  ward  the  next  day  he  noticed  that  the 
child   was   carrying   its   head   very  low   on  its  shoulders,  and 


STUDY   OF   THIRTY   CERVICAL   FIBROIDS.  121 

ventured  a  diagnosis  of  cervical  spina  bifida,  though  there  was 
no  external  indication  thereof.  It  died  in  a  few  days,  and  the 
specimen  showed  very  well  the  condition  of  hidden  cervical 
spina  bifida. 

III.  Br  Barbour  showed — (a)  A  fibrous  tumour  of  ovary, 
so  wedged  in  pelvis  and  pressing  against  uterus  that  a  diagnosis 
of  uterine  tumour  was  made.  There  were  pressure  symptoms  on 
the  rectum,  and  there  was  difficulty  at  the  operation  in  pulling 
the  tumour  past  the  promontory.  (6)  Euptured  ovarian  cyst, 
with  pseudo-myxoma  peritonei.  The  cyst  contained  gelatinous 
material.  The  omentum  was  hanging  down  like  an  apron, 
infiltrated  with  this  tissue,  (c)  Dermoid  tumour  of  ovary, 
with  a  twisted  pedicle.  The  tumour  had  been  diagnosed  as  a 
fibroid  of  ten  years'  duration,  and  during  that  time  it  had  not 
produced  any  symptoms.  The  patient  was  suddenly  seized 
with  symptoms  partly  suggestive  of  torsion  of  the  pedicle,  but 
instead  of  sickness  there  were  symptoms  of  obstruction  of  the 
bowels,  which  was  found  on  operation  to  be  due  to  paralysis 
of  the  bowel,  the  result  of  commencing  peritonitis.  There  was 
difficulty  in  overcoming  the  paralysis  of  the  bowel  for  two  or 
three  days,  but  the  patient  did  very  well. 


IV.  A  CLINICAL  AND  ANATOMICAL  STUDY  OF  THIRTY 
CERVICAL  FIBROIDS  REMOVED  BY  ABDOMINAL 
HYSTERECTOMY. 

By  F.  W.  N.  Haultain,  M.D.,  F.R.C.P.  Ed.,  Physician  for  Diseases  of 
Women,  Deaconess  Hospital,  Edinburgh. 

As  is  well  known,  the  cervix  and  body  of  the  uterus  essentially 
differ  in  their  anatomical  aspects  from  the  earliest  periods  of 
the  development  of  the  organ.  These  striking  differences  they 
maintain   throughout    the   life  of  the  individual,  not  only  in 


122 


STUDY   OF   THIKTY   CERVICAL   FIBROIDS, 


their  anatomical,  but  also  in  their  physiological  and  pathological 
features.  Upon  such  it  is  not  necessary  to  dwell,  except  in  the 
essential  particular  which  is  associated  with  the  development 
and  growth  of  uterine  fibro-myomata,  which  forms  the  text  of 
the  following  observations. 

The   development   and   growth    of   these   tumours   in    the 
cervix  is  rare,  and  is  said  to  account  for  about  5  per  cent,  only 


Fig.  1. 


of  all  cases  of  uterine  fibro-myomata.  In  this  connection  my 
operative  experience  is  not  in  strict  accord,  as  out  of  260  cases 
of  hysterectomy  for  these  neoplasms,  I  have  on  thirty  occa- 
sions met  with  their  primary  development  in  this  situation. 
But  when  the  large  number  of  corporeal  fibro-myomata  I  have 
seen,  in  which  operative  treatment  was  unnecessary,  is  con- 
sidered, this  percentage  may  fairly  be  taken  as  about  the 
normal.      At   the   same   time,   it   must   be   remembered   that 


BY   DR   F.    W.   N.    HAULTAIN.  123 

submucous  cervical  fibroids  aud  interstitial  tumours  of  the 
intravaginal  portion  are  by  no  means  rare,  and  are  removable 
through  the  vagina. 

Divisions  of  Cervix. — To  study  and  classify  these  growths 
one  must  take  into  account  the  anatomical  description  of  the 
cervix  into  three  portions — supravaginal,  inter  vaginal,  and 
intravaginal,  which  is  of  such  great  importance  in  the  descrip- 
tion of  hypertrophic  conditions.  These  may  be  described  as 
being  differentiated  from  one  another  by  the  attachment  of  the 
vaginal  walls ;  the  "  intra  "  being  below  the  attachment  of  the 
anterior  vaginal  wall,  the  "  supra  "  being  above  the  attachment 
of  the  posterior  wall,  and  the  "  inter  "  the  intervening  portion 
between  these  two  (Fig.  1).  Tumours  of  the  intravaginal 
portion  alone  do  not  here  call  for  description,  as  their  removal 
by  the  abdominal  route,  or  indeed  the  removal  of  the 
uterus,  is  uncalled  for,  and  they  may  thus  be  dismissed.  I 
therefore  confine  myself  to  those  associated  with  the  intervaginal 
and  supravaginal  portions  with  subsequent  involvement  of  the 
intravaginal  portion. 

1.  Table  of  cases  in  which  cervix  alone  ivas  involved — 

(a)  Supravaginal  portion      .         .  {^fir'  1}  4] 

(b)  Supravaginal  and  intervaginal  /Posterior  4\   A^ 

portion  [Anterior  2| 

(c)  Supravaginal,        intervaginal,  /Posterior  sl-.^ 

and  intravaginal  portions      (Anterior  4 J      - 

2.  Cases  complicated  with  corporeal  fibroids        .         7  7 

3.  Case  complicated  with  one  month's  pregnancy         1  1 

30 

The  supravaginal  tumours  were  more  of  the  subperitoneal 
type,  and,  with  one  exception,  grew  from  the  posterior  wall, 
and  embedded  themselves  downwards  in  the  recto-vaginal 
septum.     They  thus  bulged  the  posterior  vaginal  wall  forwards, 


124 


STUDY   OF   THIRTY   CERVICAL   FIBROIDS, 


but  in  no  way  affected  the  free  portion  of  the  cervix,  except 
that  it  was  displaced  high  up  behind  the  pubis,  and  was  diffi- 
cult to  reach. 

Six  supravaginal  and  intervaginal  growths  were  met  with, 
two  in  the  anterior  and  four  in  the  posterior  wall.  As  the 
result  of  the  want  of  involvement  of  the  intravaginal  portion, 
the  external  os  was  in  no  way  affected,  and  remained  as  a 
slight  projection  on  the  base  of  the  tumour,  with  a  small  open- 
ing at  its  tip  (Fig.  2).     All  these  tumours  were  sufficiently 


Fig.  2.— Fibro-myoma  involving  supravaginal  and  intervaginal  portions  of  cervix 
anterior  wall.    Dotted  line  shows  peritoneum. 

large  to  fill  the  brim  of  the  pelvis,  and  grew  upwards  and 
downwards,  assuming  the  typical  ovoid  shape.  The  bladder  in 
all  instances  was  displaced  upwards  into  the  abdomen — in  the 
anterior  tumours  by  the  actual  growth  itself,  and  in  the 
posterior  by  the  stretching  of  the  anterior  wall.  In  each  the 
growth   was   incarcerated   in    the    pelvis,   and,   as   might    be 


BY  DR   F.    W.    N.    HAULTAIN.  125 

expected,  gave  rise  to  well-marked  pressure  symptoms,  particu- 
larly associated  with  micturition. 

The  entire  cervix  was  involved  in  twelve  instances.  In 
eight  the  growth  developed  in  the  posterior  wall,  in  four  the 
anterior  wall.  In  these  cases,  through  the  stretching  and 
thinning  of  the  uninvolved  cervical  lip,  the  os  externum  was 
much  dilated,  and  easily  admitted  the  tip  of  the  finger. 

All  were  sufficiently  large  to  fill  the  true  pelvis,  and  thus 
conformed  to  the  typical  ovoid  shape,  as  in  the  previous 
tumours. 

The  disposition  of  the  peritoneum  is  of  interest,  as  it 
naturally  is  varied  according  to  the  position  of  the  tumour  in 
the  anterior  or  posterior  wall.  When  anterior,  the  retro- 
uterine pouch  is  in  no  way  interfered  with,  and  the  peritoneum 
extends  downwards  over  the  upper  third  of  the  posterior 
vaginal  wall;  while  in  the  posterior  tumours  the  peritoneum 
is  lifted  up  over  the  top  of  the  growth,  and  thus  separated 
from  its  usual  relations  to  the  vaginal  roof.  In  the  latter 
instances  the  tumour  occupied  the  recto-vaginal  septum,  and 
was  in  close  apposition  to  the  rectum  and  vagina,  a  relation  of 
very  considerable  importance  with  regard  to  operative  removal 
(Fig.  3).  When  anteriorly  situated,  the  peritoneum  along  with 
the  bladder  is  lifted  high  in  the  abdomen,  and  separated  from 
the  anterior  abdominal  wall  for  a  considerable  distance. 

In  all  of  the  cases  but  one  the  growths  were  uninodular, 
although  in  eight  instances  they  were  associated  with  fibro- 
matous  nodules  in  the  uterine  body.  In  the  multinodular 
growth  which  grew  from  the  anterior  wall,  and  involved  the 
entire  cervix,  the  displacement  of  the  surrounding  organs  was 
extreme.  The  bladder  was  drawn  round  to  the  right  side  of 
the  pelvis,  while  the  fundus  uteri  was  displaced  into  the  retro- 
uterine pouch.  The  entire  brim  of  the  pelvis  was  filled  by 
the  tumour,  and  the  usual  landmarks  were  thus  completely 
obliterated  (Fig.  4). 


126 


STUDY   OF   THIRTY   CERVICAL   FIBROIDS, 


Clinical  Features. — As  might  be  expected  from  the  situation 
and  size  of  the  tumours,  intrapelvic  pressure  symptoms  were 
mainly  in  evidence.  These  in  the  majority  of  instances  were 
associated  with  the  functions  of  the  bladder,  mainly  in  the 
direction  of  retention  of  urine.  Firstly,  this  was  complained  of 
at  or  about  the  menstrual  period,  when  the  tumour  was  tem- 
porarily engorged,  but  later  it  occurred  at  other  times ;  and  in 


Fig.  3.— Unencapsulated  cervical  fibroid  of  posterior  wall  involving  entire  cervix.    Dotted 
line  shows  peritoneum  and  obliteration  of  retro-uterine  pouch. 


one  instance  it  was  permanently  present;  here  the  irregular 
pressure  on  the  base  of  the  bladder  continued  to  make  cathe- 
terisation  difficult,  as  from  the  prolonged  distension  of  the 
bladder  it  remained  atonic  and  pouched,  so  that  unless  the 
catheter  actually  passed  into  the  upper  diverticulum  only 
partial  evacuation  was  procured.  Pain,  as  the  result  of 
pressure   on   the   pelvic   nerves,  is,   strangely   enough,   not   a 


BY   Dll   F.    W.    N.    HAULTAIN. 


127 


marked  symptom ;  it  is  by  no  means  so  evident  as  in  incar- 
cerated fibroids  of  the  body.  Haemorrhage  was  a  most  unequal 
symptom,  and  in  only  ten  of  the  twenty-two  cases  could  be 
considered  severe;  seven  of  these  being  instances  where  the 
entire  cervix  was  involved.  In  eight  there  was  neither 
monorrhagia  or  metrorrhagia. 

It   is   probable   in    some   instances    the   haemorrhage    was 
increased  by  some  attempt  at   the   expulsion   of   the   tumour 


Fro.  4.— Fibro-myoma  involving  the  entire  cervix.    Small  nodule  in  uterine  body. 


below  the  mucosa.  In  this  type  not  only  is  there  a  special 
disposition  towards  haemorrhage,  but  also  a  tendency  to  slough- 
ing and  gangrene,  probably  due  to  some  impairment  in  the 
blood  supply.  Haemorrhage  must  not,  therefore,  be  considered 
a  constant  symptom,  although  frequently  present. 

In   my   own   experience,   in   only   two   instances   did    the 
tumour  show  any  signs  of  degeneration.     These  were  oedematous 


128  STUDY   OF   THIRTY   CERVICAL   FIBROIDS, 

and  gangrenous.  In  a  case,  however,  of  Professor  Simpson's,  in 
which  I  had  the  honour  of  assisting  him  in  its  removal,  a  large 
central  degeneration  cyst  was  present,  similar  to  those  met 
with  in  the  so-called  fibro-cystic  myomata  of  the  uterine  body ; 
the  contents  were  spontaneously  coagulable  on  evacuation. 

Operation. — The  operation  for  the  removal  of  these  growths, 
though  by  no  means  simple,  does  not  present  the  formidable 
difficulties  which  from  their  situation  one  would  anticipate,  as 
they  are  usually  readily  enucleated  from  their  surroundings. 
Perhaps  the  most  troublesome  difficulties  are  the  absence  of  the 
usual  landmarks  from  the  displacement  of  the  surrounding 
structures,  the  close  relation  to  the  ureters,  and  the  inability  to 
recognise  the  elongated  and  stretched  uterine  arteries.  In  one 
case,  where  the  tumour  arose  from  the  anterior  lip  and  filled 
the  brim  of  the  pelvis,  incarcerating  the  retroverted  fundus  with 
the  ovaries  in  the  pouch  of  Douglas,  and  pushing  the  distended 
bladder  far  round  to  the  right  side,  when  the  abdomen  was 
opened  nothing  but  a  large  indefinite  mass  could  be  seen,  which 
required  to  be  enucleated  from  its  subperitoneal  bed  before  the 
true  relation  of  parts  could  be  made  out  (Fig.  4). 

As  might  be  expected,  the  incision  in  the  vaginal  wall  is 
preferably  to  be  commenced  anteriorly  after  stripping  the 
bladder  down.  In  a  typical  case,  the  following  may  be  described 
as  the  method  of  operating.  On  opening  the  abdomen,  the 
small  uterine  body  will  be  seen  situated  on  the  top  of  the 
growth.  This  is  laid  hold  of  by  a  pair  of  strong  vulsella  and 
forcibly  pulled  upwards.  The  infundibulo  pelvic  ligaments  are 
tied  and  the  broad  ligament  cut.  The  round  ligaments  are 
similarly  dealt  with.  In  anterior  growths,  the  loose  peri- 
toneum covering  the  tumour  is  then  incised  from  pelvic  wall 
to  pelvic  wall  anteriorly,  and,  with  the  bladder,  is  freed  from 
the  mass ;  this  is  usually  easily  accomplished,  but  care  must 
be  taken  not  to  tear  through  the  large  plexus  of  vesical 
veins,  which   may  cause  most  troublesome  haemorrhage.     The 


BY   DR   F.    W.    N.    HAULTA1N.  129 

uterine  arteries  are  now  ligatured  as  low  as  possible  and 
divided. 

An  opening  is  then  made  into  the  anterior  vaginal  fornix. 
This  is  enlarged  laterally,  extending  round  the  tumour  mass, 
the  vaginal  wall  being  gripped  in  small  sections  by  forceps 
before  cutting.  By  this  means,  bleeding  from  the  vaginal 
arteries,  wherever  present,  is  controlled,  and  they  can  be  easily 
detected  and  tied. 

When  the  growth  is  from  the  posterior  wall,  the  loose 
peritoneum  covering  is  incised  in  like  manner  and  the  tumour 
enucleated  from  the  rectum  and  its  bed,  care  being  taken  to 
keep  close  to  the  tumour  laterally  to  avoid  the  ureters.  After 
enucleation,  the  anterior  vaginal  vault  is  opened  and  the  tumour 
removed  by  a  process  similar  to  that  in  the  anterior  growth. 
After  all  vessels  have  been  tied,  the  bed  of  the  tumour  is 
packed  with  gauze  and  the  end  drawn  down  into  the  vagina. 
The  two  layers  of  the  peritoneum  are  now  stitched  completely 
over  the  gauze  by  continuous  thin  suture  in  Lembert  fashion. 
The  gauze  is  withdrawn  after  forty-eight  hours,  by  which  time 
all  oozing  has  been  controlled.  The  vagina  is  then  gently 
syringed  out  daily  with  warm  sterilised  water.  In  supravaginal 
growths,  after  enucleation  the  remaining  portion  of  the  cervix 
is  cut  across  and  treated  by  the  subtotal  method. 

In  posterior  growths,  the  close  connection  of  the  tumour  to 
the  rectum  from  which  it  has  practically  been  stripped,  forms  a 
distinct  sourcef  of  danger,  in  so  far  as  the  bed  of  the  tumour 
may  subsequently  become  infected  by  the  Bacillus  coli  directly 
from  the  bowel.  In  three  of  my  cases  this  complication 
occurred,  and  in  two  of  these  it  proved  fatal.  It  is  well,  there- 
fore, in  these  instances  to  see  that  the  bowel  is  not  only  freely 
evacuated  but  cleansed  by  means  of  weak  antiseptic  enemata. 

In  cases  where  there  is  a  distinct  muscular  capsule  to  the 
growth,  it  is  undoubtedly  safer  to  incise  it  transversely  from 
side  to  side  at  the  same  level  as  the  peritoneal  incision,  and 

I 


130  STUDY  OF   THIRTY   CERVICAL  FIBROIDS, 

proceed  to  enucleate  the  tumour'  from  the  capsule.  The  cavity 
which  remains  is  then  packed  with  gauze  and  the  end  drawn 
through  the  vagina;  by  this  means  there  is  no  baring  of  the 
rectum,  and  the  risks  of  infection  from  this  source  minimised 
(Fig.  5). 


Fig.  5.— Uterus  and  posterior  cervical  fibro-myoma  removed,  the  latter  enucleated 
from  its  capsule. 


In  these  cases  the  tumour  may  be  enucleated  after  vertically 
splitting  the  uterine  body  and  thus  reaching  &ie  bed  of  the 
tumour  from  above.  This  is  the  method  adopted  by  Bland- 
Sutton  and  Eutherforcl  Morison.  A  distinct  capsule,  however, 
is  not  always  present,  and  complete  removal  is  essential. 

The  combination  of  large  corporeal  and  cervical  fibro- 
myomata  is,  fortunately,  rare,  and  the  difficulty  and  danger  of 
their  removal  is  very  great.  Personally,  I  know  of  no  operation 
in  gynaecology  which  offers  so  great  difficulties,  from  the  want 
of  definite  landmarks  and  the  distortion    of   surrounding   im- 


BY   DE   F.    W    N.    HAULTAIN.  131 

portant  organs.  Each  case  seems  more  puzzling  than  the  other. 
The  dislocation  of  the  bladder  and  ureters,  the  splitting  of  the 
layers  of  the  mesosigmoid,  and  the  want  of  room  to  work  from 
the  incarceration  in  the  true  pelvis,  all  tend  to  prevent  con- 
ventional method  of  action  and  demand  originality. 

Perhaps  the  most  interesting  of  these  it  has  been  my  fortune 
to  meet  was  the  removal  of  the  specimen  I  show  of  combined 
fibroid  and  pregnancy  five  months,  in  which  labour  was  present. 

I  have,  unfortunately,  to  record  three  deaths  in  the  thirty 
cases  operated  upon,  a  mortality  of  10  per  cent.,  which  un- 
doubtedly compares  most  unfavourably  with  my  experience  of 
hysterectomy  for  corporeal  fibroids,  which  shows  a  mortality  of 
slightly  more  than  1  per  cent. 

That  the  operation  is  legitimate,  however,  even  with  such 
results,  there  can  be  no  gainsaying,  as  the  symptoms  present  in 
all  cases  were  severe  and  dangerous,  and  doubtless  would 
shortly  have  caused  the  death  of  the  individual,  a  very  different 
status  from  the  victims  of  corporeal  fibroids,  in  whom  the 
operation  is  undertaken  for  discomfort  and  semi-invalidism,  and 
the  life  of  the  patient  is  only  threatened  in  a  comparatively  few 
instances. 

Two  of  the  deaths  occurred  in  posterior  cases,  and  were  due 
to  septic  infection;  this  was  probably  predisposed  to  by  the 
large  area  of  enucleation,  which  involved  baring  the  rectum. 
In  these  cases,  therefore,  I  now  always,  if  possibly,  enucleate 
from  their  capsule,  so  that  stripping  from  the  rectum  may  be 
avoided.  The  third  death  was  also  due  to  septic  infection  from 
a  sloughing  cervical  tumour  associated  with  a  large  corporeal 
growth. 


The  President  said  they  had  listened  with  the  greatest 
interest  and  pleasure  to  Dr  Haultain's  paper.  It  was  only 
after    seeing  a  great  number  of  cases  that   one  was  able  to 


132  STUDY   OF   THIRTY   CERVICAL   FIBROIDS, 

make  out  the  small  points  of  difference  that  existed,  more 
especially  with  regard  to  the  relationship  of  parts  to  other 
organs,  and  the  relation  of  the  tumour  to  the  uterus  itself. 
Dr  Haultain's  communication  had  greatly  cleared  up  the 
topography  of  these  cervical  fibroids,  and  would  enable  them  in 
the  future  to  classify  them  into  anterior  and  posterior 
varieties,  and  according  to  the  three  segments  of  which  the 
cervix  is  composed.  The  deductions  from  such  topographical 
knowledge  were  very  interesting  with  regard  to  treatment,  and 
to  the  close  proximity  of  the  rectum.  He  had  wondered 
when  Dr  Haultain  was  describing  his  cases,  whether  there  had  in 
any  case  been  any  infection  of  the  tumour  itself  from  the 
rectum.  His  own  personal  operative  interference  with  cervical 
fibroids  was  limited  to  two  cases :  one  which  he  had  enucleated 
from  the  cervix,  and  in  which  he  had  had  to  face  tremendous 
haemorrhage  at  the  time ;  and  the  second,  in  which  he  had  done 
a  pan -hysterectomy.  Both  cases  had  made  a  good  recovery. 
In  both  of  them  the  tumour  had  affected  the  intravaginal 
portion,  and  had  been  anterior  also  in  both  cases.  Certainly, 
he  thought  that  Dr  Haultain's  paper  showed  that  with  very 
few  exceptions  it  was  a  very  risky  thing  to  approach  these 
growths  through  the  vagina,  and  that  abdominal  hysterectomy 
was  the  right  thing  to  do.  He  was  sure  the  Society  was  much 
indebted  to  Dr  Haultain  for  bringing  the  cases  forward  in  such 
a  masterly  way. 

Dr  Barbour  said  that  the  President  had  touched  on  most  of 
the  points  he  had  intended  to  refer  to.  He  congratulated  Dr 
Haultain  on  the  clear  and  lucid  description  of  these  tumours  in 
respect  to  the  parts  of  the  cervix  from  which  they  grew,  and 
with  regard  to  the  displacement  of  the  peritoneum.  It  was  a 
very  interesting  fact  that  tumours  growing  from  the  cervix 
posteriorly  lifted  the  peritoneum  up,  and  that  the  pouch  of 
Douglas  was  displaced  to  such  a  height.  Dr  Haultain  had 
drawn  attention  to  the  interesting  fact  that  usually  the  fibroid 


BY   Dli   F.    W.   N.    HAULTAIN.  133 

tumours  of  the  cervix  were  single — that  is  to  say,  that  one  did 
not  often  see  a  fibroid  of  the  cervix  and  several  of  the  uterus ; 
and,  indeed,  that  one  might  almost  assume  that  a  cervical 
fibroid  will  be  a  single  tumour,  although  now  and  again  there 
were  exceptions.  For  that  reason  he  wondered  whether  one  of 
the  tumours  figured  was  a  cervical  fibroid.  It  seemed  to 
extend  a  good  way  up  into  the  anterior  uterine  segment,  and 
to  be  as  much  a  uterine  as  a  cervical  tumour.  He  wished  to 
ask  if  there  was  any  liability  to  kidney  complications  in  any  of 
the  cases ;  and  to  Dr  Haultain's  reply  in  the  negative,  he  said 
it  was  interesting  that  although  there  must  be  considerable 
pressure  on  the  ureters,  yet  there  was  no  disturbance  from  the 
kidneys.  Dr  Haultain  had  brought  out  an  interesting  and 
important  point  with  regard  to  the  operation — in  regard  to 
leaving  the  capsule  in  the  case  of  any  tumour  that  comes  to  be 
in  relation  to  the  rectum.  In  olden  days  the  operation  of 
enucleation  was  a  dangerous  one  for  the  patient,  and  to  have 
left  a  portion  of  the  capsule  behind,  would  have  been  con- 
sidered to  have  increased  the  risk  of  the  operation.  But  it  was 
now  evident  that  if  the  tumour  was  thoroughly  cleaned  out,  it 
was  quite  safe  to  pack  with  gauze,  and  that  with  good  drainage 
from  below,  the  risk  of  infection  was  less.  He  looked  on  the 
paper  as  a  very  important  contribution,  not  only  to  the  topo- 
graphy of  the  tumours,  but  also  as  to  the  operative  treatment, 
and  was  in  a  line  with  the  splendid  work  Dr  Haultain  had 
already  done  on  the  subject. 

Dr  Brewis  said  that  he  had  listened  with  the  greatest 
pleasure  and  with  considerable  profit  to  the  very  valuable  paper 
of  Dr  Haultain.  Dr  Haultain  had  treated  the  subject  so  fully 
and  dealt  with  it  in  so  admirable  a  manner,  that  there  was  very 
little  left  to  say.  His  experience  of  this  class  of  case  accorded 
entirely  with  that  of  Dr  Haultain,  with  one  exception.  He 
had  thought  he  had  met  with  all  possible  varieties  of 
cervical  fibroids,  but  he  found  he  had  not  mot  with  two  of  the 


134  STUDY   OF   THIRTY   CERVICAL   FIBROIDS, 

examples  that  Dr  Haultain  had  figured.     He  said  there  was 
really  nothing  to  criticise,  though  he  would  state  his  experience. 
As  to  the  frequency  of  cervical  fibroids,  his  experiences  coin- 
cided  with   that   of   Dr   Haultain.     In    10   per   cent,   of  the 
cases  requiring  abdominal  section  he  had  found  cervical  fibroids. 
Dr  Haultain  had  classified  the  tumours  into  the  usual  divisions 
of  the  cervix.     He  thought  they  might  also  be  designated  as 
submucous,     interstitial,     and    subserous.      With    regard    to 
symptoms,  every  cervical  fibroid  was  more  or  less  intrapelvic, 
and  when  growing  big  enough  gave  rise  to  pressure  symptoms. 
The  outstanding,  and  frequently  the  only  symptom,  was  reten- 
tion of  urine.     He  was  accustomed  to  tell  his  students  that  if 
a  non-pregnant  patient  above  a  certain  age  came  complaining  of 
retention  of  urine,  almost  certainly  she  had  a  fibroid  tumour, 
and  in  nine  cases  out  of  ten  it  would  be  a  cervical  fibroid.     He 
had  also  met  with  haemorrhage  in  some  of  his  cases,  and  in  such 
the  tumour  had  usually  been  of  the  submucous  variety.     As  to 
the  treatment  of  these  tumours,  the  various  anatomical  features 
they  presented  required   different    technique.      They  had   to 
avoid  the  bladder  in  front,  the  rectum  behind,  and  the  ureters 
at  the  side.     He  had  had  several  cases  of  cervical  fibroid  that 
had  been  limited  entirely  to  the  supravaginal  portion  of  the 
cervix,  and  each  case  had  been  done  by  the  supravaginal  opera- 
tion.    In   one   case   the   tumour  had  grown   backwards,   and 
opened  up  the  meso-rectum,  and  was  very  difficult  to  remove. 
He  had  had  a  number  of  cases  similar  to  the  ones  represented 
— subserous  cervical  fibroids  growing  either  from  the  anterior 
or  posterior  aspect.     In  these  cases,  after  having  opened  the 
abdomen   and   divided    the    peritoneum,   he   had   shelled  the 
tumour  out  of  its   capsule,  put  stitches  into  the  bed  of  the 
tumour,  and  drained  per  vaginam,  closing  the  abdomen  without 
removing  the  uterus.     He  had  done  this  in  subserous  tumours, 
growing  both  from  the  anterior   and  posterior  aspect  of  the 
cervix.      Submucous   or  interstitial  differed  quite  from    that 


BY   DR   F.   W.   N.   HAULTAIN.  135 

variety.  They  formed  a  more  or  less  elliptical  tumour.  If 
large,  they  filled  up  the  whole  pelvis,  and  were  very  difficult  to 
remove;  because,  as  Dr  Haultain  pointed  out,  the  uterine 
vessels  were  spread  out  alongside,  elongated,  and  difficult  to 
ligature.  From  want  of  room  it  was  also  difficult  to  avoid  the 
ureters.  He  had  removed  at  least  six  of  such  cases  by  pan- 
hysterectomy, much  as  described  by  Dr  Haultain.  In  a 
number  of  cases  he  had  found  that  this  operation  was  simpli- 
fied by  splitting  the  uterus;  after  having  divided  the  broad 
ligaments  as  far  down  as  possible,  and  pushed  down  the  bladder, 
he  had  split  the  uterus  down  vertically  from  the  fundus,  and 
enucleated  the  tumour.  Enucleation  might  be  difficult,  and 
not  safe  to  practise.  In  such  a  case,  even  without  enucleation, 
the  splitting  of  the  uterus  and  tumour  was  of  the  greatest 
service,  because  one  can  pull  up  one  half  and  ligature  the 
vessels,  and  then  do  the  same  on  the  other  side ;  it  was  then  a 
simple  matter  afterwards  to  open  the  vagina.  Enucleation  was 
of  the  greatest  benefit,  not  only  in  cervical  fibroids,  but  also  in 
corporeal  fibroids.  In  the  most  difficult  cases,  where  some- 
times one  did  not  know  where  one  was,  one  could  incise  and 
get  a  blunt  instrument  between  the  capsule  and  the  tumour 
and  shell  it  out,  and  might  shell  out  several  in  that  way. 
After  that  was  done,  that  which  had  been  very  complicated 
became  quite  simple.  He  cited  one  remarkable  case  in  which 
the  patient  had  come  to  him  after  the  eighteenth  operation. 
He  was  told  that  each  time  she  had  presented  herself  previously 
to  her  doctor,  there  was  a  fibroid  at  the  vagina,  and  that  several 
inches  of  it  were  removed.  When  the  patient  came  under  his 
care  for  the  nineteenth  operation,  he  had  removed  the  whole 
uterus.  Dr  Haul  tain's  paper  was  one  of  the  greatest  value, 
and  perfect  in  all  its  details,  not  lending  itself  to  any  criticism. 


136     HYSTERECTOMY   FOR   FIBROID   TUMOURS    IN   PREGNANCY, 


V.  HYSTERECTOMY  FOR  FIBROID  TUMOURS  IN    PREG- 
NANCY.    TWO  CASES. 

By  A.  H.  F.  Barbour,  M.D.,  University  Lecturer  on  Gyniecoloiry. 

The  interesting  paper  by  Dr  Brewis  on  two  cases  of  pregnancy, 
complicated  by  fibroid  tumours,  treated  by  hysterectomy,  read 
at  the  December  Meeting  of  our  Society,  induces  me  to  place  on 
record  two  cases  of  operation  for  similar  conditions,  performed 
during  the  last  few  months.  These  cases  differ  from  those 
recorded  by  Dr  Brewis  in  that  the  operation  was  done  at  an 
earlier  period,  when  it  was  not  a  question  of  Cesarean  section. 
Under  the  rarity  of  the  condition  I  may  mention  that  these 
are  the  first  cases  that  have  come  under  my  notice  in  connection 
with  my  experience  at  the  Eoyal  Infirmary,  which  extends  now 
over  many  years.  The  clinical  histories  of  these  cases  are  as 
follows : — 

Case  I.  Fibroid  Tumour  of  Cervix. — After  five  normal 
pregnancies  and  labours  patient  became  pregnant,  and  had 
repeated  haemorrhages  during  pregnancy,  followed  by  a  natural 
labour  at  term.  Eighteen  months  later  an  abortion  at  the  sixth 
month,  the  haemorrhage  during  the  pregnancy  preventing  her 
knowing  her  condition  until  abortion  occurred.  A  year  later, 
after  four  months'  amenorrhoea,  a  tumour  the  size  of  a  foetal 
head  discovered  in  the  pelvis,  growing  from  the  posterior  lip  of 
the  cervix  and  displacing  the  uterus  upwards.  Pan -hysterec- 
tomy a  fortnight  later.     Eecovery. 

Case  II.  Fibroid  Tumour  of  Posterior  Wall  of  Uterus. — An 
abortion  at  the  third  month,  a  year  after  marriage.  Eight 
months  later  became  pregnant  again ;  and  now,  after  four  and  a 
half  months'  amenorrhoea,  has  a  uterine  fibroid  about  4  inches 
in  diameter  to  the  right,  displacing  pregnant  uterus  to  the  left. 


DY  DR  A.  H.  F.  BARBOUR.  137 

The  tumour  has  a  broad  base  of  attachment,  and  has  rotated 
the  uterus,  so  that  the  right  appendages  lie  anterior.  As 
patient  desired  immediate  operation,  supravaginal  hysterectomy 
was  done.     Eecovery. 

A  comparative  study  of  the  cases  raises  the  following 
interesting  questions. 

As  regards  the  situation  of  the  tumour  and  the  consequent 
displacement  of  the  uterus,  we  note  that  the  cervical  fibroid 
measures  4J  inches  transversely,  2|  vertically,  and  3  antero- 
posteriorly.  It  springs  from  the  posterior  half  of  the  cervix, 
its  attachment  extending  up  into  the  lower  uterine  segment. 
It  is  a  single  tumour,  there  being  no  other  in  the  uterine  wall. 
It  must  have  been  present  for  some  time,  as  fibroid  tumours  of 
the  cervix  do  not  grow  rapidly ;  indeed  we  have  evidence  of  its 
presence  as  far  back  as  1903,  when  the  patient  had  her  sixth 
child.  The  repeated  haemorrhages  in  pregnancy  in  a  patient 
who  had  had  five  previous  normal  pregnancies  point  to  the 
development  of  this  tumour,  although  it  was  not  of  sufficient 
size  to  interfere  with  her  sixth  labour.  Her  seventh  pregnancy 
was  also  marked  by  haemorrhages,  so  frequent  that  the  patient 
was  unaware  of  her  condition  until  a  sixth  month's  foetus  was 
expelled  prematurely. 

It  is  an  interesting  fact  that  conception  occurred  with  a 
tumour  which,  making  allowance  for  its  more  rapid  growth 
during  the  early  months  of  pregnancy,  must  have  been  of 
considerable  size.  This  shows  that  the  sterility  characteristic 
of  these  tumours  is  not  due  to  their  bulk,  but  to  associated 
changes  in  the  uterine  mucosa. 

Another  interesting  question  is  how  far  the  patient  was 
gone  in  pregnancy.  She  gave  a  history  of  four  and  a  half 
months'  amenorrhoea,  and  of  having  felt  foetal  movements  for 
six  weeks,  that  is  from  the  third  month  onwards.  The  fundus 
stood  about  1  inch  above  the  umbilicus.     At  first  I  was  inclined 


138     HYSTERECTOxMY   FOR   FIBROID   TUMOURS  IN    PREGNANCY, 

to  think  that  she  was  only  four  and  a  half  months  pregnant, 
and  to  attribute  her  having  felt  foetal  movements  from  the 
third  month  to  the  fact  that  the  tumour  in  the  pelvis,  displacing 
the  uterus  upwards,  had  brought  it  into  contact  with  the 
abdominal  wall  at  an  earlier  period  than  is  usually  the  case. 
From  the  size  of  the  uterus,  however,  and  especially  the  length 
of  the  foetus,  which  measures  13  inches,  it  is  evident  that  the 
pregnancy  is  of  five  and  a  half  months'  duration.  In  this  case, 
what  she  described  as  her  last  menstruation  must  have  been 
a  haemorrhage  some  weeks  after  conception. 

The  second  case  shows  a  fibroid  tumour  of  the  posterior 
wall  of  the  uterus,  measuring  about  4  inches  in  diameter,  and 
with  a  broad  base  of  attachment  extending  from  the  level  of 
the  Fallopian  tubes  to  the  lower  uterine  segment.  Before 
operation  it  looked  is  if  we  had  to  do  with  a  tumour  attached 
fco  the  right  side  of  the  uterus,  displacing  the  pregnant  uterus 
to  the  left ;  on  abdominal  section,  however,  it  was  found  that 
the  tumour  had  caused  rotation  of  the  uterus,  so  that  the  right 
uterine  appendages  were  opposite  the  abdominal  incision. 
From  the  size  and  position  of  the  tumour,  delivery  of  a  child, 
in  the  event  of  pregnancy  going  on  until  the  child  was  viable, 
could  only  have  been  possible  by  Csesarean  section. 

These  cases  also  raise  the  interesting  question  of  the  reasons 
for  operative  interference,  and  whether  immediate  operation  was 
necessary.  In  the  case  of  the  cervical  fibroid  the  appearance 
of  the  part  of  the  tumour  presenting  at  the  vulva  decided  the 
question.  The  tumour  was  undergoing  infection,  and  though 
there  was  no  temperature  it  was  evident  that  it  would  not  be 
safe  to  allow  pregnancy  to  go  on  in  the  hope  of  getting  a  living 
child.  Even  had  the  tumour  not  been  undergoing  necrotic 
changes  it  would  have  been  a  doubtful  policy  to  temporise, 
because  labour  had  come  on  prematurely  in  the  previous 
pregnancy ;  and  to  defer  operation  until  labour  was  advanced 
would  have  greatly  increased    the   risk    to   the   patient.     The 


BY   DR   A.    H.    F.    BARBOUR.  139 

dilatation  of  the  cervix  seen  in  the  preparation  shows  that  as  a 
matter  of  fact  labour  had  already  begun,  though  no  pains  had 
been  noticed,  before  the  patient  was  on  the  operating  table. 

The  necessity  for  immediate  operation  was  not  so  obvious 
in  the  second  case.  Although  it  is  doubtful  whether  pregnancy 
would  have  gone  on  until  a  viable  child  could  have  been 
obtained  by  Cesarean  section,  yet,  had  there  been  an  opportunity 
for  keeping  the  patient  under  observation,  the  operation  might 
have  been  deferred.  In  forming  an  opinion  in  a  case  of  this 
nature  one  has  to  be  guided  by  the  patient's  wishes,  and  had 
she  been  anxious  to  run  a  certain  amount  of  risk  for  the 
possibility  of  having  a  living  child,  I  should  have  advised  delay. 
Both  the  patient,  however,  and  her  husband  wished  to  have  as 
little  risk  as  possible,  and  requested  immediate  interference. 

With  regard  to  the  operation  itself,  little  requires  to  be  said. 
In  the  first  case  pan-hysterectomy  was  performed,  care  being 
taken  to  prevent  infection  of  the  peritoneal  cavity  as  the 
tumour  was  lifted  out  of  the  pelvis.  In  the  second  case  supra- 
vaginal hysterectomy  was  performed,  the  cervix  being  left. 
In  both  cases  I  was  struck  by  the  fact  that  the  operation  of 
hysterectomy  is  not  made  more  difficult  by  the  existence  of 
pregnancy.  While  more  ligatures  are  necessary  to  control 
venous  haemorrhage,  the  stretching  of  the  peritoneum  and 
opening  out  of  the  ligaments,  resulting  from  the  pregnant 
condition,  facilitates  the  dealing  with  bleeding  points  and  the 
covering  over  of  the  pelvic  floor  with  peritoneum.  Both 
patients  made  an  excellent  recovery. 


140  EXHIBITION   OF   SPECIMENS. 

Meeting  V. — March  13,  1907. 

Dr  J.  W.  Ballantyne,  President,  in  the  Chair. 

I.  Dr  Brewis  showed — (a)  a  four  months'  fcetus  (extra- 
uterine) removed  by  vaginal  section,  and  A  portion  of  the 
placenta.     The  patient  was  aged  35 ;  had  had  five  children,  the 
youngest  of  whom  was  five  years  old  ;  the  last  period  was  on 
21st  October,  the  operation  on  22nd  February.     The  primary 
rupture  took  place  on  the  eighth  week,  as  far  as  could  be  ascer- 
tained, for  she  had  been  seized  at  that  time  with  severe  pain  in 
the  lower  abdomen,  resembling  the  pains  of  labour ;  the  pains 
were  not  followed  by  any  collapse.      The  vomiting  and  pain 
had  continued  till  the  time  of  operation.     On  examination  the 
whole  of  the  lower  abdomen  had  been  found  to  be  distended 
with  a  tense  swelling,  not  firm  and  resistant,  but  more  like  an 
ovarian  cyst.     Towards  the  symphysis,  and  in  the   left   iliac 
region,  there  was  distinct  resistance  and  dullness  on  percussion. 
Per  vaginam,  the  uterus  was  found  to  be  enlarged  and  pushed 
to  the  front  by  a  tense  cystic  swelling,  filling  up  the  posterior 
part  of  the  pelvis.     The  diagnosis  of  tubal  rupture  of  an  extra- 
uterine gestation  was  made.     He  had  operated  from  below,  as 
was  his  custom  in  most  of  these  cases.     The  patient  was  very 
feeble ;  haemoglobin  50  per  cent. ;  and  he  had  carried  out  venous 
transfusion  while  the  patient  was  getting  the  anaesthetic.     He 
had    opened   through   the  posterior   fornix   opening    into   the 
sac,   from  which   had  poured  fluid   which  looked  like   liquor 
amnii.     He   got   hold   of   a  foot  of   the  infant  and  delivered 
rapidly,   and   had   taken   away   a   piece   of   the   placenta  and 
blood-clot.      The   fcetus   was    living    at   birth;   the   cord    was 
attached  to  the  upper  part  of  the  sac ;  in  the  left  iliac  region 
was  the  rest  of  the  placenta,  but  he  had  not  considered  it  wise 
to  remove  the  placenta  from  that  site.     The  sac  was  packed 
with   gauze   (16   yards   were   used).      The    rupture   had    been 
between    the   layers   of    the    mesometrium,   the    embryo    and 


EXHIBITION    OF   SPECIMENS.  141 

membranes  had  escaped  into  the  portion  of  the  pelvis  uninjured, 
and  the  pregnancy  had  continued.  As  the  sac  enlarged,  it  lifted 
up  the  peritoneum  from  the  anterior  surface  of  the  rectum  and 
the  anterior  abdominal  wall,  and  the  explanation  of  the  vomit- 
ing was  that  the  pregnancy  had  continued — it  was  the  vomiting 
of  pregnancy.  He  took  it  that  the  sac  was  in  imminent 
danger  of  undergoing  secondary  rupture.  He  pointed  out 
the  advantage  of  operating  from  below;,  for  if  this  had  been 
opened  from  the  front  he  would  have  encountered  the  placenta 
first,  and  the  patient  would  have  succumbed  to  any  operative 
procedure  from  above.  But  from  below  the  operation  had 
been  easy  and  comparatively  safe.  The  placenta  had  not  yet 
come  away,  but  was  coming  away  in  pieces,  and  the  patient 
was  doing  quite  well. 

(&)  Large  subperitoneal  fibroid,  showing  mucoid  degenera- 
tion, with  a  very  small  pedicle. 

(c)  Cervical  fibroid,  growing  from  the  anterior  wall  of  the 
cervix,  and  removed  by  pan-hysterectomy. 

(d)  Two  dermoids  removed  from  the  same  patient,  who 
was  married  and  had  had  a  large  family. 

(e)  Double  pyosalpinx,  removed  by  the  operation  of 
hystero-salpingo-oophorectomy — it  was  a  tuberculous  case. 
The  tube  had  ruptured  at  the  time  of  operation,  and  pus 
escaped  over  the  field  of  operation;  but  the  patient  had 
recovered  without  a  bad  symptom — the  pus  being  sterile. 

(/)  Ovarian  tumour,  from  a  patient  who  had  been  operated 
on  by  Thomas  Keith,  nineteen  years  before.  It  was  a  case  in 
which  Keith  had  evidently  not  thought  it  wise  to  remove  the 
whole  tumour,  and  had  stitched  the  cyst-wall  to  the  abdominal 
wound,  leaving  a  portion  of  the  tumour.  When  the  case  came 
under  his  care,  the  tumour  had  filled  the  greater  part  of  the 
abdomen,  and  was  attached  to  a  large  surface  of  the  anterior 
abdominal  wall.  The  tumour  had  been  removed  by  taking  away 
a  great  part  of  the  anterior  abdominal  wall. 


142  EXHIBITION   OF   SPECIMENS. 

IT.  Dr  Haig  Ferguson  showed — (a)  A  pelvic  abdominal 
tumour  from  patient  set.  38,  diagnosed  as  uterine  fibroid, 
producing  severe  oedema  of  right  lower  extremity  from  pressure 
upon  right  external  iliac  vein.  This  was  practically  the  only 
symptom  caused  by  the  tumour,  as  the  patient  had  no  metror- 
rhagia, no  severe  menorrhagia,  and  only  a  copious  watery 
intermenstrual  discharge.  The  specimen  showed — (1)  large 
submucous  fibroid ;  (2)  fibroid  which  was  removed  from 
between  the  layers  of  the  right  broad  ligament,  and  which  was 
continuous  with  the  submucous  fibroid.  Apparently  the 
tumour  commenced  interstitially,  and  grew  simultaneously 
outwards  between  the  layers  of  the  broad  ligament  and  in- 
wards as  a  submucous  fibroid,  the  two  portions  being  united  by 
a  narrow  neck.  Pressure  symptoms  were  completely  relieved 
by  operation. 

(b)  Pelvis  of  primipara,  who  was  unconscious  from  acute 
eclamptic  toxsemia  at  full  time,  with  strong  labour  pains,  and 
demanding  rapid  delivery.  Head  lay  persistent  occipito- 
posterior,  and  was  not  engaged  at  the  brim.  Forceps  proved 
unavailing,  and  as  child  was  dead,  craniotomy  was  performed. 
Patient  never  regained  consciousness.  The  measurements  of  the 
pelvis  were : — Interspinous,  9 \  inches ;  intercristal,  9 £  inches ; 
conjugata  vera,  3 J  inches;  conjugata  diagonalis,  3f  inches; 
transverse  (widest  point),  5 J  inches,  (available),  4  J  inches; 
left  oblique,  4J  inches;  right  oblique,  5  inches;  cavity  fairly 
roomy;  transverse  at  outlet,  4J  inches.  Projecting  into  the 
lumen  of  the  brim  opposite  the  right  iliac  pectineal  eminence 
was  a  spinous  process,  causing  shortening  of  left  oblique 
diameter  by  J  inch,  as  compared  with  right.  Type: — The  pelvis 
was  apparently  a  justo-minor,  complicated  with  rickets.  It 
seemed  to  be  after  the  type  described  by  Litzmann,  in  that  it 
had  an  ungainly  and  angular  appearance,  and  in  the  marked 
prominence  of  the  pubic  crests.  There  was  a  slight  scoliosis. 
The  head   lay  in   the    RO.P.  position,   the   occiput   becoming 


EXOPHTHALMIC    GOITRE.  143 

impacted  on  the  abnormal  spinous  projection  on  the  right  ilio- 
pectineal  line — a  fact  which  could  be  easily  made  out  during  the 
conduct  of  the  labour,  and  necessitating  craniotomy.  Un- 
fortunately, the  birth  of  the  foetus  did  not  modify  the  toxaemic 
condition,  the  fits  continuing,  and  the  patient  dying  in  toxsemic 
coma. 


III.    EXOPHTHALMIC    GOITRE    IN    ITS    RELATION    TO 
OBSTETRICS  AND  GYNECOLOGY. 

By  Sir  J.  Halliday  Croom,  M.D.,  Professor  of  Midwifery  in  the 
University  of  Edinburgh. 

The  relationship  of  exophthalmic  goitre,  known  as  Graves' 
disease  or  Basedow's  disease,  to  pregnancy,  parturition,  and  to 
various  forms  of  gynaecological  disease,  has  received  compara- 
tively little  attention  in  this  country,  and  as  I  have  observed  a 
number  of  cases  within  recent  years,  I  venture  to  record  some 
conclusions  I  have  arrived  at,  although  I  fear  in  the  main  they 
are  negative. 

It  is  unnecessary  to  describe  the  symptoms  characteristic  of 
this  disease,  nor  in  a  short  paper  can  I  deal  with  the  theories  as 
to  its  etiology.  Suffice  it  that  amongst  many  supposed  causes 
brought  forward  by  various  authorities  we  find  changes  in  the 
blood,  changes  in  the  heart  muscle,  enteroptosis,  floating  kidney, 
auto-intoxication  from  digestive  disorders,  impairment  of  the 
lymphatic  circulation,  changes  in  the  ganglion  cells  of  the  cortex, 
changes  in  the  medulla,  lesions  of  the  sympathetic,  lesions  of 
the  restiform  bodies,  and  finally  hypersecretion  of  the  thyroid 
gland. 

This  last  point,  the  question  of  the  thyroid,  is  an  extremely 
difficult  and  important  one.  Eichardson,  whose  essay  on  the 
subject  is  classic,  says  that  the  spontaneous  enlargement  and 
hypersecretion   of   the   gland   is   more   than   improbable;  and 


144  EXOPHTHALMIC   GOITRE, 

Gibson,  in  his  able  and  valuable  paper  on  "Adaptation  and 
Compensation,"  condemns  non-functional  hypertrophy  in  any 
part  of  the  human  organism  in  characteristic  language  as  "a 
base  figment  of  the  imagination." 

As  we  shall  see  later,  there  seems  to  be  a  direct  relationship 
between  pregnancy  and  the  thyroid,  a  point  to  which  attention 
has  been  drawn  recently  by  the  researches  of  Nicholson  and 
others  into  the  connection  between  eclampsia  and  the  thyroid 
gland.  And  if  we  consider  the  undoubtedly  close  connection 
between  the  thyroid  and  metabolism  and  assimilation,  we  must 
at  least  admit  the  plausibility  of  Thomson's  claim  that  the  causa 
causans  is  a  toxaemia,  and  that  this  produces  a  perversion  or  an 
increase  in  the  quantity  of  the  thyroid  secretion.  It  is  certain 
that  pathologically  the  changes  which  take  place  in  the  thyroid 
gland  are  usually  a  parenchymatous  hyperplasia  with  changes 
in  the  colloid  material  and  degenerative  changes  in  the 
protoplasm  and  nuclei.  There  is,  however,  no  definite 
histological  change  in  the  organ  that  can  be  called  specific 
of  exophthalmic  goitre,  and  all  the  above  changes  may  be  found 
in  patients   who   present   none   of   the   symptoms   of   Graves' 


The  disease  is,  roughly  speaking,  ten  times  more  common  in 
women  than  in  men.  This  I  take  to  be  an  undisputed  fact. 
But,  judging  from  the  statistics  of  my  own  hospital  work,  which 
has  been  entirely  confined  to  the  Maternity  Hospital  and  the 
gynaecological  wards  of  the  Koyal  Infirmary  of  Edinburgh,  it 
would  seem  to  be  a  comparatively  rare  condition  associated 
either  with  pregnancy  or  uterine  affections.  At  all  events, 
looking  back  over  my  work  in  the  Maternity  Hospital,  and 
going  over  the  statistics  of  the  hospital,  which  include  15,000 
cases,  I  have  only  met  with  one  case  in  which  there  was  any 
reference  made  to  goitre,  and  in  that  case  there  were  neither 
tremors  nor  exophthalmos.  During  the  fifteen  years  in  which  I 
had  charge  of  the  gynaecological  ward  in  the  Eoyal  Infirmary,  I 


BY   PROFESSOR   SIR   J.    HALLIDAY   CROOM.  145 

met  with  only  two  cases  of  exophthalmic  goitre  which  were 
associated  with  uterine  affections ;  to  these  I  shall  refer  later. 
I  have  occasionally  seen  cases  of  exophthalmic  goitre  in  associa- 
tion with  my  colleagues  in  the  ordinary  medical  wards  of  the 
Royal  Infirmary,  but  in  these  cases,  except  irregular  menstrua- 
tion, there  was  no  affection  of  the  genital  organs  whatever. 

It  must  therefore  be  apparent  that  the  disease  must  be  more 
common  in  the  better  classes  than  amongst  those  who  attend 
hospitals;  and  from  all  that  is  known  of  its  etiology,  this  is 
just  what  one  would  expect  of  a  disease  arising,  as  it  does  very 
often,  after  shock  and  mental  anxiety  in  highly  strung  nervous 
systems. 

When  regard  is  had  to  the  age  at  which  exophthalmic  goitre 
is  most  prevalent,  we  find  that  it  coincides  with  the  active 
period  of  uterine  life.  Taking  a  table  from  Murray's  most 
interesting  paper,  I  find  that  the  youngest  case  was  15  years  old 
and  the  oldest  65.  The  most  common  period  lay  between  16  and 
35,  but  quite  a  number  occurred  between  the  ages  of  40  and  50, 
a  period  coinciding  with  the  normal  changes  which  take  place 
in  the  genital  system  at  the  menopause. 

That  there  is  a  relationship  between  the  generative  apparatus 
and  the  thyroid,  there  can  be  no  question.  My  experience 
entirely  coincides  with  that  of  Martin,  whose  extremely  able 
and  interesting  paper  has  just  been  published,  that  a  great  many 
girls  suffering  from  exophthalmic  goitre  have  special  discomfort 
during  menstruation,  and  I  have  noticed  that  the  thyroid  gland 
enlarges  in  some  cases  at  the  same  time.  It  is  not  necessary, 
nor  in  my  experience  is  it  common,  to  have  pathological  con- 
ditions of  the  pelvic  viscera  associated  with  exophthalmic  goitre. 
It  seems  to  me  that  the  periods  when  exophthalmic  goitre  is 
most  likely  to  be  developed  or  exaggerated,  are  the  three  epochs 
when  the  generative  system  is  at  the  height  of  its  activity, — at 
puberty,  at  menstruation,  and  during  pregnancy.  May  I  quote 
a  sentence  from  Martin's  excellent   work:   "Growth  is   more 

K 


146  EXOPHTHALMIC   GOITRE, 

active  than  ever  at  the  age  of  puberty,  and  with  the  onset  of 
activity  of  the  generative  organs  the  vitality  of  all  parts  of  the 
organism  is  raised,  and  the  glands  involved  in  the  metabolism 
are  put  to  an  unprecedented  strain;  especially  is  this  so  in 
the  female  sex." 

The  question  of  the  condition  of  the  thyroid  during  preg- 
nancy has  received  a  very  considerable  amount  of  attention. 
That  there  is  a  greater  or  less  increase  of  its  volume  during 
pregnancy  seems  to  me  to  be  beyond  dispute,  and  that  it 
gradually  disappears  after  delivery  is  an  ascertained  fact. 
Freund  it  was  who  first  systematically  examined  the  relations 
between  the  thyroid  gland  and  the  female  genitals.  He  arrived 
at  the  conclusion  that  the  relation  occurs  not  through  the 
nervous  system  but  through  the  blood.  Heidenreich  was  of 
opinion  that  the  pregnant  uterus  hindered  respiration,  and 
thus  led  to  an  accumulation  of  blood  in  the  gland.  The  general 
opinion,  however,  seemed  to  be  that  the  enlargement  was 
sympathetic.  Such  was  the  way  the  question  stood  when 
Lange  approached  the  subject,  and  in  a  very  interesting  and 
original  paper  discussed  the  matter,  taking  his  statistics  from 
observations  made  by  himself  from  October  1893  to  January 
1898.  The  result  of  his  examinations  very  much  corroborated 
those  of  Freund,  and  he  found  that  a  hyperplasia  of  the 
thyroid  was  an  almost  constant  concomitant  of  pregnancy.  Lange 
made  his  observations  most  carefully,  eliminating  all  apparently 
obvious  causes  leading  to  mistake.  It  is,  for  instance,  the 
tendency  of  many  pregnant  women  to  put  on  fat,  and  therefore 
he  only  took  women  with  thin  necks,  so  as  to  make  no  possible 
error ;  and,  furthermore,  in  measuring  the  neck  after  accouche- 
ment, especially  after  tedious  labour,  he  only  did  so  after 
twenty-four  hours,  as  the  neck  is  apt  to  be  turgid  and  swollen 
immediately  after  labour. 

The  important  conclusion  he  arrived  at  was  that  hyperplasia 
of  the  thyroid  is  a  physiological  appearance  in  pregnancy,  and 


BY  PROFESSOR   SIR   J.    HALLIDAY   CROOM.  147 

that  in  the  majority  of  cases  it  begins  about  the  sixth  month, 
and  ceases  at  an  indefinite  period  after  labour.  He  points  out 
that  with  kidney  affections  peculiar  to  pregnant  women  there 
is  no  hyperplasia,  and  in  an  able  paper  by  Nicholson,  this 
matter  is  very  fully  discussed.  Upon  this  matter  I  have  no 
intention  of  entering  to-night. 

Considering,  therefore,  the  frequency  with  which  this 
disease  occurs ;  considering,  further,  the  fact  that  it  occurs  in 
women  during  the  active  period  of  menstrual  life;  consider- 
ing, further,  the  intimate  connection  which  apparently  exists 
between  the  thyroid  gland  and  menstruation  and  pregnancy — 
one  would  naturally  expect  to  have  exophthalmic  goitre  more 
commonly  associated  with  uterine  conditions  than  seems  to  be 
the  case. 

Kleinwachter,  in  his  work  published  in  1890,  paid  particular 
attention  to  the  relationship  between  the  sexual  organs  and  this 
disorder,  pointing  out  that  in  many  cases  the  sexual  develop- 
ment was  wanting.  In  the  case  which  he  particularly  described, 
there  was  a  loss  of  the  hair ;  the  mammary  glands  were  atrophied, 
almost  completely  so;  the  mons  veneris  was  poor  in  adipose 
tissue  and  destitute  of  hair ;  the  labia  were  flabby,  especially 
the  minora ;  the  vulva  was  gaping ;  the  whole  vagina  was  loose, 
with  slight  prolapse  of  the  anterior  vaginal  wall;  the  portio 
vaginalis  was  scarcely  the  size  of  a  kidney  bean;  the  uterus 
was  sunk  down,  the  cavity  was  small,  with  the  walls  very  thin 
and  flabby;  both  ovaries  were  small  and  tender.  These 
changes,  in  fact,  entirely  correspond  with  senile  marasmus. 
Similar  changes  in  the  sexual  sphere  were  noted  by  Mobius  and 
Cheadle. 

Cholmogoroff  records  a  case  as  follows : — A  woman,  ret.  32. 
Eight  previous  full-term  labours,  last  in  November  1892.  Well 
built ;  moderate  development  of  subcutaneous  fat ;  no  exopthal- 
mos  ;  slight  tremor  of  the  hands ;  frequent  and  severe  attacks 
of  palpitation,  which   had   existed   before   marriage,   and   had 


148  EXOPHTHALMIC    GOITRE, 

been  explained  by  the  doctor  as  due  to  anaemia.  There  was 
considerable  increase  of  the  thyroid  gland.  This  increase  in 
the  thyroid  was  noticed  in  the  fourth  pregnancy.  The  gland 
gradually  grew  larger  with  each  pregnancy.  Patient's  mother, 
set.  60,  had  a  large  goitre,  and  a  sister  a  smaller  one.  In  the 
mother  and  sister  there  were  no  symptoms  of  Graves'  disease. 

The  patient  came  under  Cholmogoroff's  care  owing  to  a 
bleeding  of  three  weeks  in  connection  with  an  incomplete 
abortion.  The  breasts  atrophied  in  spite  of  the  pregnancy; 
before  this  the  breasts  had  been  well  developed.  In  the  end  of 
1893,  there  occurred  a  tenth  pregnancy,  resulting  in  abortion. 
The  symptoms  became  worse  in  each  succeeding  pregnancy. 

Jouin  refers  to  a  connection  between  the  menopause  and 
Graves'  disease.  He  observed  in  forty-three  cases  that  the 
uterine  lesion  preceded  the  Graves'  disease.  Improvement  in 
the  local  condition,  he  avers,  is  always  accompanied  by  improve- 
ment of  the  general  condition. 

Doleris,  on  the  other  hand,  believes  that  the  treatment  of 
the  uterine  disease  might  cure  women  having  tachycardia 
simulating  Graves'  disease,  but  in  the  case  of  those  having  true 
exophthalmic  goitre  it  would  be  imprudent  to  promise  to  cure 
them  of  their  goitre  by  treatment  directed  against  their  uterine 
disease. 

In  those  cases  that  have  come  under  my  own  observation, 
I  have  only  met  with  abnormality  in  the  sexual  organs  in  three 
cases. 

Case  I.— Sent  to  me  by  Dr  Haggart  of  Aberfeldy.  The 
patient  had  well-marked  exophthalmic  goitre.  She  was  sent  to 
my  care  specially  because  she  was  suffering  from  profuse 
menstruation  and  recurrent  attacks  of  retention  of  urine. 

On  examination,  a  fibroid  tumour  was  found  blocking  up 
the  pelvis.  On  placing  the  patient  under  an  anaesthetic,  she 
expired  at  once,  before  she  had  been  touched  with  a  view  to 


BY   PROFESSOR   SIR   J.    HALLIDAY   CROOM.  149 

operation.  This  case  is  particularly  interesting  to  me,  as  it  is 
the  only  case  that  I  ever  lost  under  the  administration  of  an 
anaesthetic.     Unfortunately,  no  post-mortem  was  permitted. 

Dr  Luke,  the  anaesthetist  to  the  Eoyal  Infirmary,  informs  me 
that  exophthalmic  goitre  is  one  of  the  most  trying  cases  with 
which  an  anaesthetist  has  to  deal.  They  are  in  many  ways 
worse  than  a  simple  goitre  or  Derbyshire  neck,  as,  owing  to  the 
extreme  nervousness  of  the  patient  and  the  great  vascular 
excitement,  the  conditions  favouring  sudden  cardiac  failure  are 
present  in  a  marked  degree,  and  conditions  are  not  improved  by 
the  possible,  and  indeed  probable,  narrowing  of  the  air- way  by 
the  thyroid  growth.  Such  cases  he  would  place,  as  far  as  risk 
is  concerned,  alongside  of  aortic  aneurysm,  and  bad  cases  of 
mitral  stenosis  and  tricuspid  regurgitation. 

Case  II. — A  single  lady,  aet.  50,  with  extremely  marked 
exophthalmic  goitre,  with  profuse  haemorrhage  almost  con- 
tinuous. She  had  a  large  ovarian  tumour  on  tha  right  side, 
and  a  polypus  projecting  from  the  cervix.  She  had  been 
practically  bedridden  for  two  years,  as  much  owing  to  the 
Graves'  disease  as  to  the  haemorrhage. 

I  first  of  all  removed  the  polypus,  and  sometime  afterwards 
performed  ovariotomy.  She  made  the  usual  recovery,  and  at 
the  end  of  a  month  left  the  Home.  It  is  interesting  here  to 
observe  the  fact  that  six  months  afterwards  the  goitre  had  very 
considerably  diminished,  and  the  exophthalmos,  tremor,  and 
tachycardia  were  very  much  better.  At  the  end  of  three  years, 
although  still  an  invalid,  and  unable  to  support  herself  by  her 
own  exertions  entirely,  the  symptoms  were  very  much 
ameliorated. 

Case  III. — One  of  the  most  interesting  cases  I  have  met 
with,  was  that  of  a  girl  with  well-marked  exophthalmic  goitre, 


150  EXOPHTHALMIC    GOITRE, 

who  had  reached  20  years  of  age  and  had  not  menstruated. 
It  was  for  the  local  condition  she  was  brought  to  me.  On 
examination,  I  found  that  the  amenorrhea  was  due  to  an 
imperforate  condition  of  the  hymen,  which  was  bulging,  and 
there  was  a  distinct  tumour  on  the  right  side  suprapubically. 
She  had  had  regularly  for  years  back  the  usual  monthly  dis- 
comfort, but  no  haemorrhage  at  all.  I  treated  the  case  in  the 
usual  way,  and  she  made  an  excellent  recovery.  There  was  no 
marked  change  in  the  condition  of  the  exophthalmic  goitre. 
I  saw  her  ten  years  after  that,  and  she  still  suffered  from 
invalidism,  due  to  her  tremors  and  tachycardia. 

I  have  no  record  of  any  special  abnormality  in  the  sexual 
organs  of  those  cases  where  the  disease  occurred  in  young 
single  women,  except  that,  in  the  majority  of  cases,  the  tendency 
was  rather  to  menorrhagia  than  to  amenorrhea.  In  one  only, 
after  the  continuance  of  the  disease  for  some  years,  amenorrhea 
became  developed.  But  as  the  girl's  emaciation  was  extreme, 
and  no  obvious  benefit  was  to  be  got  from  local  examinations, 
none  was  accordingly  made. 

On  the  other  hand,  I  have  seen  two  girls  in  whom  the 
disease  developed  just  after  puberty.  Neither  girl  menstruated 
until  she  was  about  20,  and  then  only  scantily.  Both  married, 
and  were  sterile.  On  examination,  I  found  an  infantile 
condition  of  the  pelvic  organs. 

Kleinwachter  refers  to  two  cases  in  young  women,  in  the 
first  of  which  menstruation  was  retarded  and  scanty ;  and  in 
the  second  case  the  menstrual  period  lasted  six  weeks. 

Hoedemaker  records  the  case  of  a  young  woman,  set.  29, 
who  had  suffered  from  exophthalmic  goitre  for  two  years.  In 
her  he  found  changes  similar  to  those  that  describe  the 
climacteric. 

Bamour  also  records  a  case  in  which  the  uterus  was  atro- 
phied, and  the  ovaries  and  tubes  not  palpable. 

On  the  other  hand,  in  my  experience  I  have  found,  as  I 


BY  PROFESSOK   SIR   J.    HALLIDAY  CROOM.  151 

have  said,  that  menorrhagia  is  the  symptom  when  the  disease 
is  early  and  progressive,  and  amenorrhoea  only  pronounced 
when  the  disease  is  far  advanced,  or  when  it  occurs  very 
early  in  puberty. 

With  regard  to  the  occurrence  of  the  disease  in  older 
unmarried  women,  I  have  had  occasion  to  examine  ten  such. 
In  not  one  of  these  ten  cases  have  I  found  anything  abnormal, 
except  irregular  and,  for  the  most  part,  profuse  menstruation. 
I  am  driven  to  the  conclusion,  therefore,  that  in  many  cases 
recorded,  the  atrophy  of  these  organs  was  due  more  to  the 
psychic  effect  than  to  any  result  of  the  actual  disease,  mental 
shock  being,  as  I  have  already  said,  a  very  frequent  cause  of 
this  condition.  Nothing  is  more  common  than  to  find  that  the 
menstrual  function  is  disturbed  by  psychic  and  mental  con- 
ditions, and  to  these  I  attribute  the  amenorrhoea  rather  than  to 
the  existence  of  the  disease  itself. 

Furthermore,  it  must  be  kept  in  view  that  in  a  large  number 
of  the  cases  recorded  the  amenorrhoea  and  atrophy  were  the 
consequences  not  of  the  disease  itself,  but  of  its  exhausting 
influences  and  long  duration. 

Out  of  fifteen  cases  occurring  in  women  under  30  years  of 
age,  which  have  been  under  my  own  observation,  or  have  been 
seen  with  others,  where  a  local  examination  was  made,  no 
apparent  lesion  of  the  pelvic  organs  could  be  discovered.  An 
interesting  point  is  that  there  was  no  record  of  any  dysmenor- 
rhea, and  that  the  condition  of  the  flow  was  rather  increased 
than  otherwise. 

So  far  as  the  histories  of  my  cases  are  concerned,  the  onset 
in  every  one  had  followed  more  or  less  nervous  shock.  One 
specially  interesting  case  was  that  of  a  girl,  set.  26,  who,  in 
addition  to  well-marked  Graves'  disease,  had  profuse  menstrual 
discharge,  and  at  the  same  time  had  monthly  attacks  of  mania 
coincident  with  her  menstruation,  so  bad  that  on  several 
occasions  she  had  to  be  confined  in  the  padded  ward  in  hospital. 


152  EXOPHTHALMIC    GOITRE, 

In  this  case,  after  consultation  with  my  colleagues,  I  removed 
her  ovaries,  with  a  view  first  of  all  of  controlling  the  haemor- 
rhage, and  secondly,  in  the  hope  that  the  removal  of  the  ovaries 
might  also  have  the  desired  effect  upon  the  mania.  I  heard 
from  her  regularly  for  two  years  after  the  operation,  and  she 
remained  free  of  the  maniacal  attacks  during  that  time,  but  her 
condition  of  exophthalmic  goitre  remained  unchanged,  although 
the  menopause  had  been  completely  established. 

Sanger  reports  three  cases  of  women  he  examined  with  this 
disease.  In  one  case  there  was  amenorrhoea,  which  Sanger 
explains  as  lactation  amenorrhoea.  The  uterus  was  not  atro- 
phied. 

In  the  second  case  the  menses  were  somewhat  scanty,  but 
this  Sanger  attributes  to  the  approaching  climacteric  and  the 
marked  adiposity  of  the  patient.  In  this  case  also  the  uterus 
was  not  atrophied. 

In  the  third  case  the  woman  was  pregnant. 
In  these  three  cases,  therefore,  Kleinwachter's   contention 
that  this  disease  is  associated  with  atrophy  is  not  borne  out. 
On  the  other  hand,  some,  like  Caracoussi,  have  described  several 
cases  where  there  has  been  atrophy  of  the  mammae. 

Therefore,  from  my  own  experience,  as  well  as  from  the 
records  of  the  cases  that  have  been  reported,  especially  abroad, 
I  must  arrive  at  the  conclusion  that  there  is  no  interdependence 
between  pelvic  disease  and  Graves'  disease,  because  the  same 
conditions,  such  as  fright,  or  mental  shock,  which  would 
precipitate  Graves'  disease,  would  at  the  same  time  affect  the 
pelvic  organs  as  well. 

With  regard  to  the  effect  which  pregnancy  has  on  exoph- 
thalmic goitre  and  vice  versd,  as  I  have  already  pointed  out, 
this  disease  is  practically  unknown  in  the  Maternity  Hospital 
in  Edinburgh,  and  therefore  the  records  of  the  cases  which 
occurred  under  my  charge  are  all  from  my  private  case  book. 
I  have  myself  observed  twelve  cases  of  exophthalmic  goitre 


BY   PROFESSOR   SIR   J.    HALLIDAY   CROOM.  153 

during  pregnaucy,  with  the  following  results.  In  all  of  them 
the  condition  as  to  eyes,  thyroid,  and  heart  was  very  marked. 
It  would  extend  this  paper  beyond  due  limits  were  I  to  record 
these  cases  in  detail ;  enough  for  me  to  say  that  in  eight  of  the 
twelve  the  course  of  pregnancy  was  unaltered,  and  the  delivery 
was  uncomplicated,  and,  so  far  as  I  was  able  to  judge,  the 
affection  in  each  of  those  eight  cases  was  aggravated  for  a  time 
after  the  labour  was  over. 

Of  the  four  remaining  cases,  in  Case  L,  the  patient,  set.  30, 
had  post-partum  haemorrhage,  so  profuse  as  to  require  the 
uterine  cavity  to  be  plugged.  She  recovered  slowly  from  her 
haemorrhage,  and  afterwards  suffered  from  superinvolution  of 
the  uterus.  The  labour  took  place  eight  years  ago,  and  she  has 
not  menstruated  since,  and  the  uterus  and  ovaries  remain  small 
and  atrophied.  The  exophthalmic  goitre,  though  somewhat 
modified,  is  still  sufficiently  marked  to  make  her  an  invalid. 
In  this  case  I  attribute  the  atrophy  of  the  uterus  and  ovaries  to 
the  excessive  haemorrhage. 

The  second  case  was  seen  with  the  late  Dr  Duddingstone 
Wilson.  A  lady,  set.  34,  five  months  advanced  in  pregnancy  of 
a  third  child.  AVell-marked  exophthalmos;  the  thyroid  very 
considerably  enlarged ;  pulse  140  per  minute ;  marked  tremors  ; 
profuse  perspiration.  I  was  asked  to  see  the  case  because  of 
some  haemorrhage;  diagnosis,  accidental  haemorrhage;  treat- 
ment, as  the  haemorrhage  was  slight,  palliative.  The  symptoms 
of  exophthalmic  goitre  had  been  present  for  six  months  before 
her  present  pregnancy,  and  had  been  induced,  as  she  believed, 
by  a  fall  from  a  dogcart.  Previous  to  that  accident,  she  had 
been  in  good  health,  rather  robust ;  since  then  she  had  become 
emaciated  until  the  occurrence  of  the  present  pregnancy,  when 
her  symptoms  became  slightly  aggravated,  until  during  the  past 
five  months  she  had  become  very  much  emaciated,  and  been 
unable  for  her  household  duties.  As  the  haemorrhage  increased 
very  markedly,  it  was  determined  to  terminate  the  pregnancy, 


154  EXOPHTHALMIC   GOITRE, 

and  this  was  done  by  dilating  the  cervix  and  turning.  The 
placenta  was  found  in  its  normal  situation,  the  haemorrhage  was 
comparatively  slight,  and  the  patient  recovered  very  slowly 
from  the  immediate  interference. 

In  Case  III.,  I  was  asked  to  see  a  patient,  set.  29,  pregnant 
of  a  first  child  three  months,  because  of  symptoms  of  miscarriage. 
When  I  saw  her  she  had  well-marked  exophthalmic  goitre,  the 
exophthalmos  being  very  pronounced,  and  the  goitre  but  slight. 
The  pulse  was  130  per  minute,  and  the  tremors,  though  present, 
were  not  striking.  The  miscarriage,  when  I  saw  it,  was  inevit- 
able, the  os  being  open  and  the  ovum  protruding.  I  therefore 
emptied  the  uterus,  and  although  every  precaution  was  taken, 
the  haemorrhage  was  so  profuse  that  she  was  reduced  to  pro- 
found anaemia,  and  remained  in  bed  for  three  months.  During 
this  time,  although  the  lines  of  treatment  were  mainly  those  of 
anaemia,  and  no  special  treatment  was  given  for  the  exoph- 
thalmic goitre,  yet  in  the  course  of  the  three  months  her 
symptoms  of  exophthalmic  goitre  very  much  diminished;  the 
exophthalmos  was  less  pronounced,  and  the  pulse  fell  to  under 
100.  It  is  well  worthy  of  notice  that  in  this  particular  instance 
the  result  of  the  profuse  haemorrhage  was  that  the  patient 
developed  superinvolution,  and  that  there  was  no  menstruation 
again  for  twelve  months  afterwards. 

I  saw  Case  IV.  only  after  delivery  was  over,  and  that  because 
of  a  severe  convulsion  three  hours  after  delivery.  The  con- 
vulsions occurred  at  varying  intervals,  and  with  increased 
rapidity,  until  the  patient  died  during  an  attack.  She  had  had 
during  the  whole  of  her  pregnancy  and  for  a  year  before,  well- 
marked  exophthalmic  goitre,  with  the  usual  group  of  symptoms 
of  exophthalmos,  goitre,  tremqrs,  and  tachycardia. 

There  is  no  lack  of  cases  recorded  showing  that  pregnancy 
considerably  favours  the  formation  of  this  disease.  There  are 
also  many  cases  recorded  by  others  which  show  that  pregnancy 
often  makes  this  disease  considerably  worse.     Considering  the 


BY   PROFESSOR   SIR  J.    HALLIDAY   CROOM.  155 

high  degree  of  susceptibility  of  the  nervous  system,  and  the 
well-marked  hydrsemia  and  anaemia  characteristic  of  pregnancy, 
results  such  as  this  are  what  one  would  expect. 

In  a  recent  paper,  Wilson  of  Birmingham  records  eight  cases 
of  exophthalmic  goitre  in  pregnancy  which  had  come  under  his 
notice.  In  only  two  did  menstruation  continue  normal.  In 
two  there  was  monorrhagia,  in  four  there  was  more  or  less 
amenorrhea,  and  in  one  of  these  there  was  premature  atrophy 
of  the  sexual  organs. 

Trousseau  and  Charcot  taught  that  pregnancy  had  a  favour- 
able influence  on  exophthalmic  goitre,  but  they  were  unaware  of 
the  fact  that  the  thyroid  gland  enlarges  during  pregnancy  in 
the  normal  condition.  Bucquet,  again,  on  examination  of 
twenty-one  cases,  arrived  at  the  conclusion,  first  of  all,  that 
exophthalmic  goitre  can  be  provoked  by  pregnancy  at  a  date 
more  or  less  remote  from  confinement.  The  cases  he  quotes, 
however,  are  very  uncertain,  and  his  conclusions  very  indefinite. 
Further,  he  points  out  that  when  exophthalmic  goitre  occurs 
previous  to  pregnancy,  the  influence  exerted  by  the  pregnancy 
upon  the  goitre  is  very  uncertain ;  in  his  own  words,  it  may  be 
"either  neutral,  benign,  or  aggravated."  He  further  quotes 
three  cases,  two  of  which  seem  accurate,  that  pregnancy  may 
transform  simple  goitre  into  an  exophthalmic  goitre;  and  of 
the  ten  cases  in  which  pregnancy  occurred  during  exoph- 
thalmic goitre,  one  was  unaltered,  three  were  aggravated,  and 
six  were  improved.  He  arrived  at  the  conclusion,  therefore, 
that  amelioration  of  the  symptoms  is  to  be  expected  when 
pregnancy  occurs  in  a  woman  suffering  from  exophthalmic 
goitre.  But  his  conclusions  must  be  taken  with  a  certain 
amount  of  reservation,  because  at  least  seven  of  the  cases  which 
he  quotes  were  complicated  by  typhoid  fever. 

A  more  recent  contribution  to  the  subject  is  that  of  Audebert 
of  Paris.  He  records  a  case  in  which  the  disease  developed  in 
the   seventh   month   of   pregnancy.     There   was   a  goitre  and 


156  EXOPHTHALMIC    GOITKE, 

exophthalmos,  as  well  as  much  anasarca  and  scanty  urine. 
Delivery  was  followed  by  partial  recovery,  although  the  tremors 
and  exophthalmos  persisted.  Audebert  is  inclined  to  look 
upon  the  disease  in  this  case  as  a  manifestation  of  the  auto- 
intoxication of  pregnancy.  While  a  conclusion  cannot  be 
deduced  from  one  case,  the  theory  is  interesting  and  suggestive, 
in  view  of  our  increasing  knowledge  of  the  complex  relation- 
ships of  the  thyroid  in  pregnancy. 

To  bring  the  whole  matter  to  an  issue,  it  seems  to  me  that 
the  conclusions  to  be  arrived  at  are  as  follows : — 

First,  that  exophthalmic  goitre  is  a  comparatively  frequent 
disorder  of  women. 

Secondly,  that  the  thyroid  is  enlarged  during  pregnancy. 

Thirdly,  that  exophthalmic  goitre  and  pregnancy  are  a  very 
rare  combination,  as  shown  by  the  fact  that  out  of  15,000  cases 
I  have  not  met  with  one  in  hospital  practice,  and  with  only 
twelve  in  private  and  consulting  practice. 

Fourthly,  that  the  influence  of  pregnancy  upon  exoph- 
thalmic goitre  is  very  uncertain,  and  that  in  the  majority  of 
cases  it  aggravates  it. 

Fifthly,  that  the  effect  of  exophthalmic  goitre  on  pregnancy 
is  practically  nil ;  and  that,  so  far  as  my  observations  and  those 
I  have  collated  from  other  sources  abroad  go  to  prove,  most 
pregnancies  complicated  with  exophthalmic  goitre  follow  a 
regular  even  course ;  and  that  of  the  accidents  that  occur,  the 
most  frequent  is  haemorrhage,  and  occasionally  abortion. 

Sixthly,  that  the  relation  between  pelvic  disease  and  exoph- 
thalmic goitre  is  rare,  and  that  the  effect  of  exophthalmic  goitre 
on  the  reproductive  system  is  in  recent  cases  to  cause  irregular 
menstruation,  mostly  in  the  direction  of  monorrhagia,  while  in 
very  advanced  cases  it  may  cause  amenorrhoea. 

From  these  conclusions  it  must  be  apparent,  therefore — 

1.  That  girls  suffering  from  exophthalmic  goitre  need  nut 
be  precluded  from  marrying. 


BY   PROFESSOR   SIR   J.    HALLTDAY   CROOM.  157 

2.  That  after  marriage  they  need  not  be  precluded  from 
pregnancy. 

3.  That  if  pregnancy  occurs,  there  is  no  reason,  except  in 
advanced  cases,  to  interrupt  the  pregnancy,  even  in  spite  of  the 
fact  that  the  children  of  women  with  exophthalmic  goitre  may 
be  expected,  according  to  some  authorities,  to  develop  neuro- 
pathic manifestations. 

Bibliography. 

Audebert. — Compt.  rend.  Soc.  d'obst.,  de  gynah  et  de  pcediat.  de 
Paris,  July  1906. 

Bamour. — Centralbl.f.  Gynah,  Leipzig,  1891 

Begbie. — Mori.  Journ.  Med.  Sc,  1843. 

Bucquet. — "  Goitre  exophthalmique  et  grossesse."    Paris,  1895. 

Caracoussi. — "Dissertation."     Berlin,  1889. 

Cheadle. — St  George  Hosp.  Rep.,  1878. 

Cholmogoroff. — Monatschr.  f.  Geburtsh.  u.  Gynah,  Berlin, 
Bd.  v. 

Dol^ris. — Nouv.  arch,  d'obst.  et  gynah,  Paris,  1895. 

Freund. — Deutsche  Ztschr.f.  Chir.,  Leipzig,  1890. 

Gibson. — Trans.  Med.  Soc.  London,  1904,  vol.  xxvii. 

Hodemaker. — Centralbl.f.  Gynah,  Leipzig,  1891. 

Jouin. — Nouv.  arch,  d'obst.  et  gyn.,  Paris,  1895. 

Kleinwachter. — Ztschr.f.  Geburtsh.  u.  Gynah,  Stuttgart,  1889; 
Centralbl.f.  Gynah,  Leipzig,  1890;  Ibid.,  1891;  Ibid,,  1892. 

Lange. — Ztschr.f.  Geburtsh.  u.  Gynah,  Stuttgart,  1899. 

Laycock. — Med.  Times  and  Gaz.,  London,  1864. 

Maude. — Practitioner,  London,  1891. 

Murray. — "Diseases  of  the  Thyroid  Gland."     London,  1896. 

Nicholson. — Edin.  Med.  Journ.,  August  1906. 

Kichardson. — "Thyroid  and  Parathyroid  Glands."  Phila- 
delphia, 1905. 

Theilhaber—  Arch.f.  Gynah,  Berlin,  1895. 

Wilson.— Lancet,  London,  November  1906. 


158  EXOPHTHALMIC    GOITRE, 

The  President  said  that  the  Society  had  heard  with  great 
interest  the  elaborate  paper  by  Sir  Halliday  Croom.  Although 
the  results  were  somewhat  negative  at  present,  still  the  facts 
had  been  put  before  them  in  such  a  way  that  they  knew  what 
they  were,  and  could  draw  conclusions  from  them. 

Br  Barbour  said  the  Fellows  had  to  thank  Sir  Halliday  very 
much  for  bringing  before  them  an  important  subject  which,  he 
thought,  did  not  lend  itself  very  much  to  discussion.  But  the 
paper  was  an  important  contribution  to  the  subject  on  account 
of  its  rarity.  The  importance  of  the  condition  had  been 
brought  before  him  in  connection  with  the  literature  of  frozen 
sections.  In  going  into  the  cause  of  death  in  forty  cases,  one 
of  them  (which  had  given  them  one  of  the  most  important 
sections  of  the  third  stage)  was  from  the  sudden  increase  in  the 
size  of  a  goitre,  which  caused  death  from  asphyxia,  the  post- 
mortem examination  revealing  that  otherwise  things  were 
normal.  This  showed  that  the  presence  of  goitre  might  be  a 
serious  condition  in  connection  with  the  onset  of  labour,  a 
point  which  Sir  Halliday  had  not  referred  to  in  connection 
with  his  subject.  It  would  be  interesting  to  know  whether 
any  facts  would  come  out  during  the  discussion,  with  regard  to 
its  importance  in  connection  with  labour,  for  we  would  expect 
occasionally  to  hear  of  complications  in  connection  with  labour, 
even  in  the  giving  of  the  anaesthetic.  Sir  Halliday  Croom's 
conclusions,  although  negative,  were  very  important,  because  he 
thought  that  in  the  text-books  it  was  stated  that  the  presence 
of  goitre  was  a  rather  serious  condition,  and  should  be  a  contra- 
indication to  pregnancy.  Edgar  made  as  strong  statements 
regarding  goitre,  as  in  connection  with  heart  affections,  stating 
that  patients  with  Basedow's  disease  should  not  marry.  It 
would  be  reassuring  to  be  able  to  tell  patients  that  goitre  in 
pregnancy  was  not  such  a  serious  condition.  As  to  the 
gynaecological  aspect  of  the  question,  the  results  there  seemed 
to  be  negative   also.      He   thought  Sir   Halliday  had  shown 


BY   PROFESSOR   SIR   J.    HALL1DAY   CROOM.  159 

that  the  occurrence  of  goitre  with  pelvic  conditions  must  be 
looked  upon  as  a  coincidence.  He  had  himself  had  two  cases 
— (1)  a  patient  with  a  fibroid  tumour,  who  had  been  sent  to  him 
for  operation ;  but  the  patient  had  a  goitre  without  exophthalmos, 
but  of  sufficient  size  to  be  a  contra-indication  to  operation,  and 
he  had  sent  her  to  Professor  Chiene,  who  had  removed  the 
goitre,  and  the  patient  had  then  returned  to  have  the  fibroid 
removed.  (2)  The  second  case  was  one  who  had  come  for 
a  minor  operation — the  repair  of  the  perineum.  The  condition 
not  being  an  urgent  one,  he  had  thought  it  better  not  to 
operate.  He  thanked  Sir  Halliday  for  his  very  important 
clinical  contribution  to  the  Society. 

Br  Brewis  said  he  was  sorry  he  was  quite  unable  to  discuss 
the  paper.  All  he  knew  of  exophthalmic  goitre  in  relation  to 
gynaecology  and  obstetrics,  he  had  learnt  that  night.  He  had 
great  pleasure  in  expressing  his  admiration  for  the  very  able 
and  interesting  paper  that  Sir  Halliday  Croom  had  given  them. 
He  could  recollect  two  cases  of  exophthalmic  goitre  occurring  in 
gynaecology.  The  patients  were  both  young  girls,  and  in  both 
of  them  there  was  menorrhagia.  In  one  case  there  was  a  large 
retroverted  uterus  to  account  for  the  menorrhagia,  and  in  the 
other  a  small  intra-uterine  polypus.  These  were  the  only 
instances  of  exophthalmic  goitre  he  remembered.  He  had 
operated  several  times  on  patients  with  large  goitres — removing 
ovarian  tumours  and  fibroid  tumours,  and  had  had  no  hesita- 
tion— his  only  concern  was  with  regard  to  the  anaesthetic. 
The  conclusions  Sir  Halliday  had  drawn  were  of  great  value. 

Br  Ritchie  had  listened  with  very  much  pleasure  to  Sir 
Halliday  Croom's  paper,  and  he  was  specially  interested  with 
his  conclusions.  In  relation  to  marriage,  goitre  stands  in  a 
different  position  from  Graves'  disease.  During  pregnancy  the 
former  would  certainly  become  worse ;  in  Graves'  disease  the 
result  on  the  thyroid  would  be  uncertain.  Although  Trousseau 
and  Charcot  had  recommended  marriage  with  the  expectation 


160  EXOPHTHALMIC    GOITRE, 

that  pregnancy  would  cure  exophthalmic  goitre,  Trousseau  had 
later  a  somewhat  sad  experience  of  the  effect  of  pregnancy  on 
that  disease.  Dr  Kitchie  was  interested  to  note  Sir  Halliday's 
experience  of  post-partum  haemorrhage  in  Graves'  disease, 
because  Lawson  Tait's  was  similar.  The  etiology  of  exophthalmic 
goitre  was  not  known,  but  Sir  Halliday  had  made  a  very  strong 
case  for  its  being  primarily  nervous. 

Dr  Oliphant  Nicholson  said  he  had  listened  with  great 
interest  to  Sir  Halliday  Croom's  paper.  He  had  attended  two 
cases  of  pregnancy  complicated  by  typical  Graves'  disease 
during  the  last  five  years,  both  in  multiparas,  and  both  improved 
markedly  afterwards.  With  a  disease  like  exophthalmic 
goitre,  which  ran  a  very  uncertain  course,  and  which  might  end 
in  spontaneous  cure  in  two  or  more  years,  it  was  difficult  to 
say  at  what  stage  of  the  disease  pregnancy  had  supervened; 
whether  in  the  stage  of  progression,  or  at  the  stage  in  which 
improvement  was  just  setting  in.  In  some  cases  the  disease 
might  be  apparently  cured  after  pregnancy,  but  it  was  difficult 
to  say  whether  or  not  the  cure  was  really  due  to  the  pregnancy. 
In  one  of  his  cases,  in  the  later  months  of  pregnancy,  the 
tachycardia  had  improved  very  much,  the  size  of  the  thyroid 
had  diminished  a  great  deal,  and  all  the  symptoms  became  less 
pronounced.  In  the  puerperium  things  improved  still  more, 
and  later  on  the  symptoms  passed  entirely  away.  This  patient 
had  since  been  under  the  care  of  Dr  Giles,  and  was  regarded  as 
completely  cured.  The  whole  question  of  the  influence  of 
pregnancy  upon  different  diseases  was  a  most  interesting  and 
important  one;  pregnancy,  undoubtedly,  exerted  a  beneficial 
influence  on  some  diseases,  and  a  baneful  one  on  others.  He 
was  strongly  of  opinion  that  the  explanation  of  the  different 
effects  produced  was  to  be  found  in  the  manner  in  which  the 
condition  of  pregnancy  modified  the  thyroid  activity.  As 
regards  labour  in  the  cases  mentioned,  both  were  difficult. 
He  had  not  then  known  the  dangers  of  chloroform  in  such 


BY  PROFESSOR   SIR   J.    HALLIDAY   CROOM.  161 

cases,  and  had  given  a  large  quantity,  and  the  patient  had  not 
seemed  any  the  worse  for  it.  He  wondered  whether  the 
danger  of  anaesthetics  in  these  cases  was  a  mechanical  one  from 
suffocation,  owing  to  the  size  of  the  goitre,  or  whether  there 
was  in  this  disease  any  special  tendency  to  heart-failure.  He 
had  had  no  special  difficulty  with  regard  to  the  breathing.  In 
both  cases  there  was  considerable  post-partum  haemorrhage  in 
the  form  of  a  steady  oozing.  This  kind  of  haemorrhage  was 
what  one  might  expect  in  cases  of  Graves'  disease,  owing  to  the 
type  of  circulation  present;  characterised  by  a  marked  relaxa- 
tion of  all  the  smaller  blood-vessels.  Sir  Halliday  Croom  did 
not  mention  anything  about  the  lactation  in  these  cases;  in 
both  his  cases  there  had  been  a  very  great  secretion  of  milk. 
The  connection  between  the  thyroid  gland  and  lactation  was 
very  obscure,  indeed  the  whole  subject  of  the  thyroid  in  relation 
to  pregnancy  was  so  paradoxical,  that  at  present  one  could  draw 
no  definite  conclusions  at  all.  When  thyroid  was  given  to 
nursing  women  it  might  increase  the  secretion  of  milk,  and  in 
cows  Hertoghe  had  shown  that  it  acted  as  a  marked  galactagogue. 
In  myxcedema,  even  after  the  menopause  was  past,  if  one  gave 
very  large  doses  of  thyroid,  it  happened  sometimes,  as  Bramwell 
had  recorded,  that  the  breasts  commenced  to  secrete  milk 
abundantly.  On  the  other  hand,  in  animals  the  mammary 
gland  sometimes  secreted  milk  in  large  quantities  after  the 
thyroid  gland  had  been  removed.  This  happened  in  a  bitch 
from  which  he  (Dr  Nicholson)  had  removed  the  entire  thyroid 
gland  a  year  previously.  This  animal  was  not  pregnant,  and 
yet  the  breasts  became  gorged  with  milk,  and  pups  from 
another  bitch  were  suckled  on  two  different  occasions.  In  the 
present  state  of  our  knowledge  it  was  impossible  to  reconcile 
such  contradictory  observations.  It  was  a  good  thing  that  Sir 
Halliday  had  brought  up  the  subject  of  thyroid  gland  and 
pregnancy,  because  it  was  one  that  gained  every  year  in  im- 
portance, and  seemed  to  have  been  much  neglected  in  the  past. 

L 


162  EXOPHTHALMIC    GOITRE, 

Dr  Church  was  glad  he  had  had  the  pleasure  and  honour  of 
hearing  Sir  Halliday's  paper  on  this  important  subject.  A  few 
years  ago,  on  analysing  1000  cases  of  his  own,  he  had  come 
across  one  case  where  exophthalmic  goitre  existed.  It  was  in 
the  case  of  a  lady's  last  pregnancy,  and  twins  were  born.  He 
thought  the  trend  of  the  discussion  had  been  to  show  that 
pregnancy  instead  of  increasing  and  aggravating  the  condition 
seemed  to  be  a  curative  agent.  It  was  so  in  the  case  to  which 
he  referred.  Though  the  symptoms  had  been  most  marked 
before  pregnancy,  she  got  almost  entirely  free  of  them  after 
the  twins  were  born.  One  child  had  died ;  the  other,  now  aged 
14  or  15  years,  was  subject  to  epilepsy,  but  that  disease  was 
in  the  family.  In  regard  to  this  far-reaching  subject  he  had 
thought  it  well  to  mention  this  case. 

Dr  B.  P.  Watson  wished  to  mention  a  case  under  his  care 
of  exophthalmic  goitre  associated  with  gynaecological  disease. 
There  was  monorrhagia,  dysmenorrhea,  and  pain  in  the  back. 
There  was  marked  exophthalmos,  with  a  history  of  the  patient 
having  become  very  nervous  of  late  years,  subject  to  frequent 
sweatings,  intermittent  attacks  of  diarrhoea,  and  marked  tremors. 
In  every  way  it  presented  the  characteristics  of  exophthalmic 
goitre.  He  had  found  that  she  had  a  large,  tender,  retroverted 
uterus,  which  was  rather  fixed  at  the  time  of  examination. 
Under  treatment  the  uterus  had  become  smaller  and  movable, 
and  was  replaced,  and  a  pessary  inserted,  and  from  that  time 
onwards  the  symptoms  of  the  exophthalmic  goitre  were  less 
marked.  This  was  eighteen  months  ago,  and  now  there  was 
only  slight  exophthalmos  ;  she  was  not  nearly  so  nervous,  and 
was  very  much  improved.  She  had  had  one  child  five  years 
ago,  and  no  other  since ;  but  whether  the  sterility  was  due  to 
the  exophthalmic  goitre  or  to  the  position  of  the  uterus,  he 
could  not  say. 

Sir  Halliday  Groom,  in  reply,  said  he  had  really  no  reply  to 
make.     The  only  object  of  writing  a  paper  was  to  record  one's 


BY  PROFESSOR   SIR  J.    HALLIDAY   CROOM.  163 

own  personal  experience  so  far  as  possible.  And  as  he  had  had 
the  fortune  to  have  some  hospital  appointments  for  some  years, 
he  had  thought  it  right  to  record  the  experience  he  had  had. 
He  did  not  think  it  would  serve  any  good  purpose  for  him  to 
go  over  all  the  points  suggested  or  spoken  of  that  evening.  He 
thought  he  had  referred  to  them  all  pretty  fully  in  his  paper. 
He  thanked  the  Society  for  the  way  it  had  received  the  paper. 


Meeting  VI.— May  8,  1907. 
Dr  J.  W.  Ballantyne,  President,  in  the  Chair. 

I.  The  following  gentleman  was  elected  an  Ordinary  Fellow 
of  the  Society:— A.  M.  Dick,  M.B.,  Ch.B.,  Koyal  Infirmary, 
Edinburgh. 

II.  Dr  Haig  Ferguson  showed — (a)  uterus  with  adeno- 
carcinoma of  the  body,  removed  from  a  woman,  set.  42, 
married,  and  with  two  children ;  the  patient  was  also  the  subject 
of  myxcedema.  She  had  suffered  from  metrorrhagia  for  some 
time,  and  after  being  curetted,  the  report  of  the  pathologist  was 
that  the  condition  was  one  of  potential  malignancy.  He  had, 
however,  no  doubt  from  the  clinical  condition,  and  removed  the 
uterus  per  vaginam,  because  the  patient  was  so  very  fat.  He 
thought  the  ovaries  were  also  malignant,  but  the  report  upon 
them  was  that  there  was  a  marked  fibrosis,  and  no  evidence 
of  malignancy.  The  special  interest  of  the  case  was  that  it 
was  one  of  adeno-carcinoma  in  a  muciparous  woman. 

(b)  Extra-uterine  pregnancy,  removed  from  a  woman 
from  whom  four  years  ago  he  had  removed  the  left  Fallopian 
tube  for  pyosalpinx,  leaving  behind  the  left  ovary,  because  it 
was  so  densely  adherent.     From   the   right   side,  at  the  same 


164  Exhibition  of  specimens. 

time,  he  removed  the  ovary  for  a  small  ovarian  cyst  about  the 
size  of  a  tangerine  orange,  but  had  left  the  tube  on  that  side. 
Two  months  ago  there  were  symptoms  of  extra-uterine  preg- 
nancy, and  he  had  then  removed  the  right  tube  with  a  tubal 
pregnancy,  in  which  there  was  an  attempt  at  tubal  abortion. 
This  was  a  distinct  case  of  migration  of  the  ovum.  The  left 
ovary  had  ovulated,  and  the  ovum  must  have  found  its  way 
into  the  right  tube,  though  the  migration  was  not  a  long  one, 
for  the  left  ovary  was  prolapsed  and  adherent  and  close  to  the 
right  side. 

(c)  Double  pyosalpinx,  from  a  young  lady  recently 
married.  She  had  complained  of  abdominal  pain,  the  result  she 
thought  of  a  boxing  match  with  her  husband.  On  both  sides 
of  the  uterus  were  great  masses,  and  distinct  evidence  of  the 
gonococcus  was  found. 

III.  JJr  Haultain  showed — (a)  A  fibeo-myoma  of  the  round 
ligament,  3  lbs.  in  weight,  quite  distinct  from  the  uterus,  (b) 
Section  showing  tubercular  endometritis,  from  a  patient 
who  had  complained  of  no  symptoms.  She  had  been  recom- 
mended to  him  on  account  of  sterility.  On  examination,  an 
anteflexed  uterus  was  found.  There  was  a  history  of  some  slight 
pain  (heat  the  patient  termed  it)  after  making  water.  He 
decided  to  dilate  the  cervix  and  curette,  and  the  report  of  the 
uterine  scrapings  was  that  it  was  tubercular.  Then,  upon 
examining  the  urine,  tubercle  bacilli  were  found. 

IV.  Dr  W.  Fordyce  showed — (a)  carcinoma  of  the  uterus 
(three  specimens — two  cervical,  one  corporeal),  removed  by 
vaginal  hysterectomy;  (b)  uterus  showing  combined  fibroid 

TUMOUR    AND    CARCINOMA;    (c)    INTERSTITIAL    FIBROID    SHOWING 

necrobiosis;  (d)  cervical  fibroid  tumour;  (e)  multiple 
fibroids  of  uterus,  removed  for  pressure  symptoms;  (J) 
multiple  fibroids,  removed  for  post-climacteric  haemorrhage. 


EPILEPSY   AND   THE  STATUS    EPILKPTICUS. 


165 


V.  EPILEPSY  AND  THE  STATUS  EPILEPTICUS  IN  CON- 
NECTION WITH  PREGNANCY  AND  LABOUR,  WITH 
ILLUSTRATIVE  CASES. 


By  Robert  Jardine,  M.D.,  Professor  of  Midwifery  in  St  Mungo's 
College,  Glasgow;  Senior  Physician  to  the  Glasgow  Maternity 
Hospital. 

In  most  works  on  midwifery  the  subject  of  epilepsy  is  dis- 
cussed in  a  few  sentences  of  general  remarks.  Again,  in  some 
books  on  epilepsy,  the  effect  of  pregnancy  and  labour  on  the 
condition  is  hardly  mentioned.  It  is  thus  difficult  to  gain 
information  on  the  matter. 

In  his  recently  issued  book  on  epilepsy,  Dr  W.  Arden 
Turner  gives  his  experience  of  the  influence  of  pregnancy, 
the  puerperium,  and  lactation  in  forty-one  epileptic  women,  with 
a  history  of  sixty-one  pregnancies.  He  tabulates  the  results  in 
the  following  way  : — 


Quickening  induced  a  relapse  in 
P/egnancy  was  the  original  cause  in 
„         induced  relapse  in 
„         was  temporarily  beneficial  in 
made  no  difference  in 
Accouchement  was  the  original  cause  in 

„  induced  a  relapse  in    . 

Lactation  was  the  original  cause  in  . 
„         induced  a  relapse  in 


7  cases. 

2  „ 
14  „ 

6  „ 

1  „ 

5  „ 
17  „ 

3  „ 

6  ., 


Total  pregnancies 


61 


Forty-one  cases. — Of  twenty-five  of  these  cases  the  family  or 
other  history  bearing  upon  heredity  was  studied,  and  thirteen 
cases,  or  52  per  cent.,  gave  a  history  of  family  epilepsy  or 
alcoholism,  a  percentage  which  corresponds  with   that   ascer- 


166       EPILEPSY  AND  THE  STATUS  EPILEPTICUS, 

tained  as  the  relative  proportion  of  a  family  predisposition 
amongst  epileptics  in  general. 

In  the  two  cases  where  pregnancy  was  given  as  the  original 
cause,  the  women  were  both  young,  and  pregnant  for  the  first 
time.  In  one  of  the  cases  where  there  was  freedom  from  attack 
in  one  pregnancy,  the  fits  became  more  frequent  in  a  second 
pregnancy.  He  says:  "There  are  undoubted  cases  on  record 
in  which  fits  have  been  permanently  arrested  by  pregnancy, 
and  others  in  which  a  temporary  remission  has  been  observed ; 
but  it  will  be  seen  from  the  figures  here  given,  that  it  is  more 
common  to  find  a  relapse  of  the  attacks,  or  the  conversion  of  a 
minor  type  of  the  disease  into  the  combined  major  and  minor 
type.  Nerrlinger's  figures  on  this  subject  show  that  of  ninety- 
two  women  with  one  hundred  and  fifty-seven  pregnancies,  28  per 
cent,  showed  complete  cessation  of  the  fits  during  pregnancy, 
and  35  per  cent,  were  made  distinctly  worse." 

In  regard  to  accouchement  and  the  puerperium,  he  says: 
"  There  were  five  cases  in  which  the  disease  clearly  originated 
at  this  time,  and  seventeen  in  which  it  led  to  a  serious  relapse. 
Of  the  first  series,  the  onset  was  in  the  form  of  serial  epilepsy, 
or  the  status  epilepticus  (puerperal  eclampsia),  and  the  disease 
continued  in  a  chronic  form  for  many  years  afterwards.  In 
one  case  it  commenced  during  the  fourth  confinement,  and  in 
three  others  during  the  first.  These  cases  are  particularly 
interesting,  as  they  argue  strongly  in  support  of  the  view  of 
Fere,  that  puerperal  eclampsia,  like  many  other  '  eclampsias,' 
is  merely  epilepsy  in  an  acute  form,  and  that  the  disease,  once 
started  in  this  way,  may  persist  for  years.  Two  cases  were 
illustrative  of  this,  by  the  fact  that  after  the  original  eclamptic 
attack  the  further  continuance  of  the  malady  was  in  the  form 
of  minor  seizures  over  a  period  of  eighteen  and  ten  years 
respectively. 

"  Of  the  second  series — those  cases  in  which  a  relapse  was 
caused  by  confinement — there  were  two,  in  which  a  remission 


BY  PROF.  ROBERT  JARDINE.  167 

of  twelve  and  eighteen  months  respectively  was  broken  by  the 
eclamptic  seizures  of  the  puerperium.  In  the  others  they 
merely  formed  an  incident  in  the  course  of  the  confirmed 
disease. 

"It  was  not  uncommon,  in  cases  of  already  existing 
epilepsy,  for  puerperal  convulsions  to  be  delayed  untiLthe  later 
pregnancies. 

"The  incidence  of  serial  epilepsy,  at  or  immediately  suc- 
ceeding parturition,  is  therefore  a  common  feature  in  epileptic 
women,  and  raises  the  question  as  to  the  diagnosis  of  some 
forms  of  puerperal  eclampsia.  A  history  of  pre-existing  attacks 
would  determine  the  diagnosis  of  epilepsy ;  while  the  existence 
of  a  neuropathic  family  history,  or  the  presence  of  stigmata  of 
degeneration,  would  point  to  eclamptic  attacks  as  being  of 
epileptic  nature.  The  presence  of  albuminuria  does  not  of 
necessity  form  the  main  element  in  the  differential  diagnosis,  as 
albumen  has  been  found  in  the  post-paroxysmal  urine  of 
epileptics  (Voisin  and  Peron),  although  it  is  not  of  common 
occurrence. 

"  It  is  therefore  clear  that  many  cases  of  puerperal  eclampsia 
are  really  examples  of  serial  epilepsy,  or  the  status  epilepticus, 
induced  during  the  puerperium  in  predisposed  and  neuropathic 
persons." 

I  have  given  these  long  quotations  from  Dr  Turner,  as  they 
represent  the  views  of  a  man  who  has  had  a  very  large 
experience  in  epilepsy.  With  most  of  his  statements  I  am  in 
agreement,  but  I  cannot  agree  with  the  statement  that  many 
cases  of  puerperal  eclampsia  are  really  examples  of  serial 
epilepsy,  or  the  status  epilepticus.  I  have  now  seen  consider- 
ably over  one  hundred  cases  of  puerperal  eclampsia,  and,  before 
the  present  series,  there  were  only  two  which  I  considered 
were  really  epileptic  cases.  In  one  of  them  there  was  no 
albumen  in  the  urine,  and  in  the  other  there  was  a  considerable 
quantity,  but  in  the  latter  case  there  was  a  distinct  history  of 


168  EPILEPSY  AND   THE  STATUS   EPILEPTICUS, 

previous  epileptic  seizures.  The  two  conditions  resemble  each 
other  so  closely  that  it  is  difficult  to  distinguish  between  them, 
but  there  are  so  few  cases  of  eclampsia  which  subsequently 
have  fits,  even  in  connection  with  pregnancy,  that  I  think  we 
are  justified  in  concluding  that  a  true  case  of  puerperal  eclampsia 
is  not  one  of  epilepsy.  It  is  impossible  to  follow  up  the  sub- 
sequent history  of  hospital  cases,  but  in  my  private  cases  I 
have  not  met  with  one  in  which  epilepsy  has  developed.  In 
this  connection  it  will  be  interesting  to  hear  the  experience  of 
others,  and  in  that  way  we  may  get  the  results  of  a  fairly  large 
number  of  cases. 

Case  I. — Mrs  T.,  tet.  27,  iii.-para,  full  time,  was  admitted  to 
the  Glasgow  Maternity  Hospital  on  27th  February  1907,  at 
7.30  A.M.,  with  a  history  of  having  had  twelve  fits  since 
4.25  a.m. 

The  patient's  father  died  in  an  asylum,  where  he  was  confined 
apparently  on  account  of  melancholia.  Her  mother  is  alive  and 
well.  She  had  had  seven  sisters,  one  of  whom  died  at  the  age 
of  20,  after  having  had  epileptic  fits  for  six  years.  The  other 
sisters  are  quite  healthy,  but  one  is  very  rickety.  She  had  no 
brothers.  She  had  always  been  a  healthy  woman,  and  had 
never  had  any  serious  illness.  There  was  no  history  of  any 
injury  and  no  evidence  of  syphilis.  She  had  never  had  a  fit 
prior  to  the  morning  of  admission. 

The  patient  was  married  on  6th  February  1903 ;  her  first 
child  was  born  in  October  of  the  same  year,  and  the  second  in 
June  1905.  Both  children  were  delivered  with  forceps  at  the 
patient's  home.     She  had  had  no  miscarriages. 

During  the  present  pregnancy  the  patient's  health  had  been 
good.  There  had  been  no  swelling  of  the  face  or  legs,  and  no 
headache  until  the  evening  before  admission.  On  that  evening 
she  had  complained  of  headache,  and  had  not  felt  well,  but  there 
was  no  other  symptom  until  she  took  the  first  fit  at  4.25  a.m. 


BY   PKOF.    KOBEliT   JAKDINE.  169 

On  admission,  the  patient  was  quite  unconscious,  and  had 
several  fits  in  the  reception  room  before  she  was  removed  to 
the  labour  ward.  The  fits  were  of  the  ordinary  eclamptic  type. 
There  was  no  cry  at  any  time.  The  pulse  was  full  and  bound- 
ing, and  the  respirations  were  hurried. 

I  saw  the  patient  at  10  a.m.,  and  up  to  that  time  she  had 
had  twenty-one  fits.  She  was  at  once  put  under  chloroform, 
and  16  fl.  oz.  of  blood  were  drawn  from  a  vein  in  the  right  arm, 
and  3  pints  of  saline  solution  (1  dr.  of  sodium  chloride  and 
acetate  to  each  pint)  were  transfused.  "While  this  was  being 
done,  I  found  that  the  os  was  about  half  dilated,  so  I  finished 
the  dilatation  manually  and  delivered  the  child  by  version. 
The  uterus  retracted  well,  but  there  was  considerable  bleeding 
from  the  cervix,  which  had  been  lacerated  bilaterally.  After  I 
had  allowed  her  to  lose  a  good  deal  of  blood  I  stitched  the 
cervix  with  catgut.     The  pulse  remained  fairly  full  and  strong. 

The  delivery  was  finished  at  10.45  A.M.,  and  the  patient  was 
free  from  fits  until  6.20  p.m.  (i.e.,  an  interval  of  eight  hours). 
During  this  time  she  had  been  able  to  swallow  6  fl.  oz.  of  milk, 
3  fl.  oz.  of  imperial  drink,  gr.  viii.  of  calomel,  and  later  a  dose  of 
magn.  sulph.,  and  although  she  was  not  sufficiently  conscious  to 
answer  questions,  she  could  be  roused  when  spoken  to.  From 
6.20  p.m.  to  8.20  p.m.  she  had  fourteen  fits.  A  hot  pack  was 
given  at  8  p.m.,  and  from  10  p.m.  on  the  27th  until  3  a.m.  on 
the  28th  (i.e.,  for  five  hours)  she  had  no  fits.  At  11.15  p.m.  an 
intravenous  injection  of  two  pints  of  the  saline  solution  was 
given  into  the  left  arm.  After  midnight  the  patient  perspired 
freely.  The  pulse^rate  had  varied  from  96  to  116,  the  tempera- 
ture from  100*2°  to  101  '4°  R,  and  the  respirations  were  28. 
The  urine  was  found  to  be  quite  normal,  without  a  trace  of 
albumen. 

28th  February. — The  fits  began  again  at  3  A.M.,  and  she  had 
from  four  to  seven  per  hour  until  10.30  am.  At  3.15  a.m.  and 
6.30  a.m.  30  grains  of  chloral  and  60  grains  of  potassium  bromide 


170  EPILEPSY  AND   THE  STATUS   EPILEPTICUS, 

were  given  per  rectum.  Part  of  the  first  injection  was  returned, 
but  the  second  was  retained.  At  1Q.30  A.M.,  an  intracellular 
injection  of  2  pints  of  the  usual  saline  solution  was  given 
beneath  the  right  breast,  and  the  fits  became  less  numerous. 
At  12.45  an  attempt  was  made  to  draw  off  some  cerebro -spinal 
fluid,  but  none  could  be  obtained,  although  the  needle  was 
inserted  four  times.  Venesection  was  now  performed  in  the 
right  arm  and  9  fl.  oz.  of  blood  were  withdrawn,  and  2  pints  of 
saline  solution,  with  double  the  quantity  of  sodium  acetate, 
were  infused.  The  fits  remained  infrequent  until  3  p.m.,  when 
they  again  became  more  numerous  and  gradually  increased  in 
number  until  she  had  thirteen  between  8  and  9  p.m.  In  the 
afternoon,  between  3  and  5  p.m.,  three-quarters  of  a  grain  of 
morphia  was  given  hypodermically,  in  three  doses,  without  the 
least  apparent  effect  on  the  fits.  At  9  p.m.,  30  gr.  of  chloral 
and  60  gr.  of  potassium  bromide  were  given  by  the  rectum,  but 
the  fits  continued  at  the  rate  of  twelve  per  hour.  At  10.30 
P.M.,  lumbar  puncture  was  again  tried,  and  at  this  time  a  little 
over  a  fl.  oz.  of  cerebro-spinal  fluid  was  withdrawn.  The  fluid 
was  very  slightly  opalescent,  but  did  not  contain  more  blood 
than  could  be  accounted  for  by  the  puncture.  A  slight  deposit 
settled  from  the  fluid,  and  this  was  found  to  consist  of  poly- 
morphonuclear leucocytes  with  a  larger  number  of  lymphocytes 
(small  mononuclear  leucocytes).  The  withdrawal  of  the  cerebro- 
spinal fluid  did  not  produce  any  change  in  the  patient's  condition. 
The  fluid  escaped  from  the  needle  by  drops,  except  during  the 
fits,  when  it  ran  freely.  Between  the  fits  there  did  not  seem 
to  be  any  increase  in  the  tension. 

After  the  fluid  was  withdrawn  a  dose  of  stovaine  was 
injected,  and  almost  immediately  there  was  a  lessening  of 
movements  in  the  legs  during  the  fits,  but  the  fits  continued  to 
recur  about  every  five  minutes.  In  a  few  minutes  there  was 
absolute  paralysis  of  the  lower  limbs.  The  paralysing  effect 
spread  up  to  the  arms,  and  movement  in  them  became  much 


BY  PROF.  ROBERT  JARDINE.  171 

less  marked.  The  diaphragm  was  not  affected.  Shortly  after 
the  stovaine  had  been  administered,  the  movements,  which  had 
all  along  been  much  more  marked  on  the  right  side,  now  became 
confined  to  the  left  side.  In  a  short  time  the  fits  ceased  to 
affect  the  left  side  and  returned  to  the  right.  The  patient 
became  extremely  collapsed,  and  the  pulse  disappeared  entirely 
from  the  wrist.  Strychnine  (^  gr.)  was  given  hypoclermically, 
and  a  pint  of  hot  milk  and  3  fl.  oz.  of  brandy  were  injected  into 
the  stomach  through  a  tube.  The  pulse  rapidly  returned  to  the 
wrist,  but  the  patient  remained  collapsed  for  a  considerable  time. 

1st  March. — The  patient  remained  in  much  the  same  con- 
dition all  day.  The  pulse  kept  remarkably  good,  the  skin 
acted  well,  the  bowels  moved  freely,  and  plenty  of  urine  was 
passed,  partly  by  catheter  and  partly  unconsciously  in  bed. 
The  patient  was  fed  at  intervals  with  milk,  water,  and  brandy 
by  the  stomach  tube.  At  5.50  p.m.  2  pints  of  the  usual  saline 
solution  were  infused  into  the  abdominal  walls,  and  at  night 
I  gr.  of  morphia  was  injected  subcutaneously.  The  fits  occurred 
at  the  rate  of  from  six  to  fourteen  per  hour. 

2nd  March. — At  8  a.m.  the  fits  became  much  more  frequent, 
and  she  had  twenty  between  8  and  9  A.M.,  and  thirty  between 
9  and  10  a.m.  ;  the  fits  were  slighter  than  on  the  previous  days, 
but  the  patient  passed  almost  immediately  from  one  to  another. 
The  pulse  was  still  remarkably  good,  but  the  patient's  general 
appearance  was  bad.  The  fits  hardly  affected  the  legs,  and  the 
movements  of  the  arms  were  not  nearly  so  marked  as  during 
the  first  two  days.  An  attempt  was  made  to  examine  the  fundi 
oculi  with  the  ophthalmoscope,  but  nothing  abnormal  could  be 
detected  except  that  the  discs  looked  rather  too  red  No  optic 
neuritis  could  be  detected.  The  superficial  layers  of  the  cornese 
were  beginning  to  show  evidence  of  destruction,  and  this,  with 
the  continuous  movements  of  the  head,  made  the  examination 
very  difficult.  Between  12  noon  and  1  p.m.  the  patient  had  the 
greatest  number  of  fits  during  any  hour,  viz.,  thirty-two. 


172  EPILEPSY  AND  THE   STATUS   EPILEPTICUS, 

At  this  time  Mr  Hogarth  Pringle  kindly  saw  the  patient 
with  me,  and  we  discussed  the  advisability  of  trephining,  but 
concluded  that  it  would  be  of  no  avail. 

From  6  p.m.  the  patient  gradually  sank,  and  she  died  at  7.40 
P.M.  without  any  other  change  taking  place  in  her  condition. 
The  rectal  temperature  taken  immediately  after  death  was 
104-2°  F.     The  number  of  fits  recorded  was  774. 

The  fits,  though  so  numerous,  did  not  appear  to  be  very 
exhausting.  All  along  they  were  much  more  marked  on  the 
right  side  than  on  the  left,  except  for  a  short  time  after  the 
injection  of  the  stovaine.  As  a  rule,  they  commenced  with 
twitchings  of  both  upper  eyelids,  especially  of  the  right,  followed 
by  conjugate  deviation  of  the  eyes  to  the  right,  the  right  arm 
and  right  leg  were  then  affected  and  the  left  side  only  very 
slightly.  During  the  tonic  stage  the  patient  did  not  become 
so  cyanosed  as  is  ordinarily  seen  in  epileptic  or  eclampsia 
seizures,  and  she  never  gave  a  cry.  The  fits  lasted  from  half  a 
minute  to  two  minutes,  and  the  tonic  and  clonic  stages  were  of 
much  the  same  duration. 

For  the  first  two  days  no  albumen  could  be  detected  in  the 
urine,  and  even  later  there  was  never  more  than  a  very  faint  trace. 
Towards  the  end  some  finely  granular  tube-casts  were  found 
on  centrifugalising  the  urine.  At  no  time  did  the  patient 
vomit,  not  even  after  the  stomach  tube  had  been  passed. 
There  was  some  retching  after  a  few  of  the  fits,  but  that  was 
all.  There  was  no  jaundice.  The  knee-jerks  were  absent. 
The  highest  temperature  recorded  was  that  taken,  per  rectum, 
immediately  after  death,  viz.,  104*2°  F.  The  skin  acted  well 
during  the  whole  of  the  last  three  days,  and  abundance  of  urine 
was  excreted.     There  was  no  oedema  at  any  time. 

The  child,  a  male,  was  delivered  by  podalic  version.  It 
weighed  7f  lbs.  At  birth  it  was  asphyxiated,  but  was  easily 
resuscitated.  It  remained,  however,  extremely  blue  during  the 
whole  of  the  27th  February,  and  the  colour  never  became  quite 


BY  PROF.  ROBERT  JARDINE.  173 

satisfactory,  especially  in  the  arms  and  legs.  It  lived  three 
days,  and  during  that  time  its  body  was  more  or  less  in  a  state  of 
rigidity,  the  stiffness  becoming  much  more  marked  at  intervals. 
It  had  many  of  these  fits  of  rigidity,  although  there  were  no 
convulsive  attacks.  At  times  the  body  assumed  a  position  of 
opisthotonos,  and  it  could  be  lifted  by  placing  one  hand  under 
the  head  and  another  under  the  heels.  When  these  fits  of 
rigidity  came  on,  it  gave  a  peculiarly  distressing  cry  and  then 
became  very  cyanosed.  It  was  very  restless,  and  cried  a  great 
deal.  Its  urine  contained  a  considerable  amount  of  albumen. 
Chloral  hydrate  was  given  to  it  in  grain  doses  every  hour  at 
first,  and  finally  every  half-hour,  and  it  gradually  grew  quieter, 
but  whether  this  was  due  to  the  action  of  the  chloral  or  to  the 
increasing  weakness  it  was  impossible  to  say. 

A  post-mortem  examination  was  performed  on  both  bodies 
by  Dr  Carstairs  Douglas. 

The  Mother. — On  exposing  the  dura  mater  a  number  of 
small  haemorrhages  were  seen,  some  punctiform  and  others 
slightly  larger,  due  to  rupture  of  venules  within  the  membrane. 
The  whole  venous  system  of  the  membrane  was  engorged  to  a 
striking  degree,  the  engorgement  being  very  evident  in  the 
vicinity  of  the  superior  longitudinal  sinus.  The  engorgement 
was  much  more  marked  on  the  left  side  of  the  brain.  The 
meninges  stripped  off  quite  easily,  and  there  was  no  evidence  of 
any  thickening  or  of  inflammatory  adhesions.  The  brain  sub- 
stance was  somewhat  firmer  than  usual.  No  lesion  could  be 
detected.  About  an  inch  of  the  upper  end  of  the  spinal  cord 
was  removed,  and  it  appeared  to  be  quite  normal. 

Microscopic  examination  of  sections  from  the  motor  area 
showed  that  the  nerve  cells  were  normal.  A  small  aneurismal 
dilatation  was  observed  on  one  of  the  minute  arteries. 

Thorax. — Both  lungs  were  adherent  and  showed  evidence  of 
old  pleurisy.  The  lung  tissue  was  fairly  normal  The  heart 
was  normal  except  that  the  tricuspid  valve  was  dilated. 


174        EPILEPSY  AND  THE  STATUS  EPILEPTICUS, 

Abdomen. — The  liver  showed  a  slight  nutmeg  condition. 
The  spleen  was  congested,  pulpy,  and  enlarged.  The  kidneys 
were  both  smaller  than  normal.  The  capsules  stripped  off 
readily.  The  substance  was  pale  and  firm.  The  cortical  area 
in  both  was  diminished  in  size.  The  uterus,  ovaries,  and  tubes 
were  normal. 

Microscopic  examination  of  sections  of  the  kidneys  showed 
evidence  of  acute  nephritis.  There  were  some  haemorrhages 
and  blocking  of  the  tubules  with  debris. 

The  Child. — The  body  was  plump  and  well  nourished.  The 
skull  was  harder  than  usual.  The  meninges  were  healthy.  The 
brain  was  soft  and  pulpy,  and  showed  a  fair  amount  of 
vascularity,  but  not  quite  as  marked  as  in  the  case  of  the 
mother.     There  was  no  indication  of  haemorrhage  in  any  part. 

Abdomen. — The  liver  was  of  the  usual  size ;  a  little  pale  and 
spotty  in  parts  and  engorged  along  the  margin.  The  spleen 
was  of  ordinary  size  and  consistence.  The  kidneys  were  lobu- 
lated  and  normal  in  appearance,  but  somewhat  smaller  than 
usual. 

Microscopic  examination  of  the  kidneys  showed  evidence  of 
congestion,  but  not  so  marked  as  in  the  mother's.  There  were 
some  haemorrhages,  and  some  of  the  tubules  showed  exudate. 

Remarks. — The  differential  diagnosis  between  epilepsy  and 
eclampsia  is  very  difficult,  and  some  alienists  seem  to  think  the 
two  conditions  are  identical.  If  there  is  a  history  of  previous 
epileptic  seizures,  I  think  one  would  be  justified  in  looking  upon 
the  case  as  epileptic.  The  condition  of  the  urine  will  not  be  of 
much  assistance  unless  there  is  a  large  quantity  of  albumen  in 
it.  I  have  never  yet  seen  a  case  of  eclampsia  in  which  there 
was  no  albumen  in  the  urine.  I  am  aware  that  such  cases  have 
been  recorded,  but  may  not  these  have  been  cases  of  epilepsy  ? 
In  the  case  just  recorded  there  was  no  albumen  in  the  urine  at 
the  onset.     At  first  I  looked  upon   the   case   as   an   ordinary 


BY  PROF.  ROBERT  JARDINE.  175 

eclamptic,  but  when  I  found  there  was  no  albumen  in  the  urine, 
and  the  fits  began  to  recur,  I  concluded  that  we  were  dealing 
with  a  case  of  epilepsy.  Towards  the  end  of  the  case  there  was 
a  trace  of  albumen  in  the  urine,  but  that  was  what  was  to  be 
expected. 

The  status  epilepticus  is  a  condition  seen  frequently  enough 
in  asylums.  During  a  seizure  the  number  of  fits  may  be  very 
great.  Dr  Turner  says  that  in  a  case  of  Leroy's  there  were  488 
fits  in  twenty-four  hours  and  1000  in  three  days,  and  in  a  case 
of  Parsons'  there  were  1400  in  four  weeks.  Turner  has  seen 
2080  in  eight  weeks,  673  in  ten  days,  820  in  five  days,  and  as 
many  as  289  in  twenty-four  hours.  In  my  case  there  were  774 
fits  in  the  eighty-eight  hours  from  the  onset  until  death,  but 
during  fourteen  of  these  hours  the  patient  was  free  from  fits,  so 
that  the  774  fits  occurred  in  seventy-four  hours,  an  average  of 
over  ten  per  hour,  and  in  one  hour  there  were  thirty-two.  In 
the  last  twenty-four  hours  there  were  407,  and  in  the  last 
twelve  hours  no  fewer  than  261.  It  seems  almost  incredible 
that  any  constitution  could  stand  such  a  terrible  strain  for  so 
long. 

In  regard  to  treatment,  drugs  seem  to  have  no  effect.  It 
will  be  noticed  that  the  fits  ceased  for  eight  hours  after  bleeding, 
saline  infusion,  and  delivery.  After  a  hot  pack  they  also  ceased 
for  one  hour,  and  again  for  five  hours  after  a  cellular  transfusion. 
After  the  intracellular  infusion  and  the  second  bleeding  and 
third  (intravenous)  infusion,  they  lessened,  but  did  not  entirely 
cease.  The  final  intracellular  infusion  seemed  to  have  no 
effect.  Eleven  pints  of  saline  solution  was  used,  seven  of  them 
directly  into  the  vein.  In  the  third  infusion  I  doubled  the 
quantity  of  sodium  acetate.  I  did  this  in  the  hopes  of  neut- 
ralising any  lactic  acid  which  might  have  formed  in  the  blood. 
Lactic  acid  has  been  found  to  be  present  in  the  blood  of 
eclamptics,  and  it  has  been  suggested  that  the  efficiency  of  my 
solution  is  due  to  the  neutralising  effect  of  the  sodium  acetate. 


176  EPILEPSY   AND   THE   STATUS    EPILEPTICUS, 

The  patient's  blood  must  have  been  well  diluted,  and  as  the 
kidneys  and  skin  were  acting  so  well,  one  would  have  expected 
that  if  a  toxin  were  present  it  would  have  been  flushed  out. 

The  removal  of  the  cerebro-spinal  fluid  did  no  good.  The 
tension  did  not  seem  to  be  raised  except  during  the  fits.  I 
tried  the  injection  of  stovaine,  but  the  effect  was  very  alarming, 
and  for  a  time  I  thought  the  heart  would  be  paralysed.  The 
injection  of  hot  milk  and  brandy  into  the  stomach  and  -fa  of  a 
grain  of  strychnine  hypodermically  had  a  splendid  effect  upon 
the  heart,  and  soon  brought  the  pulse  back  to  the  wrists.  If  I 
should  ever  have  another  such  case  to  treat,  I  shall  be  inclined 
to  try  the  effect  of  an  injection  of  potassium  bromide. 

[By  a  curious  coincidence  at  the  date  on  which  I  read  this 
paper,  I  had  under  my  care  in  hospital  two  cases  of  epilepsy, 
and  I  also  admitted  a  third  one  about  ten  days  later.  I  shall 
give  short  notes  of  these  three  cases. 

Case  II. — A.,  jet.  34,  ii.-para,  was  admitted  to  hospital  on 
28th  April  1907,  under  the  care  of  Dr  Munro  Kerr,  and  she 
came  under  my  care  on  1st  May,  when  I  took  up  duty. 

The  patient's  first  child  was  born  four  years  ago,  and  died 
in  November  1906,  with  cerebral  symptoms  following  a 
discharge  from  the  ear.  Previous  to  her  first  pregnancy  the 
patient  had  never  had  any  convulsions,  but  when  the  pregnancy 
was  three  or  four  months  advanced,  fits  had  commenced  to  occur, 
and  at  that  time  as  many  as  fifty  had  occurred  in  twenty-four 
hours.  Since  this  pregnancy  she  had  had  attacks  of  petit  mal 
every  few  weeks.     These  attacks  had  become  less  frequent  of  late. 

On  24th  April  the  patient  complained  of  headache,  and  on 
the  25th  she  had  one  fit,  on  the  26th  four  fits,  on  the  27th 
eight  fits,  and  on  the  28th  nine  fits. 

On  admission,  the  patient  was  conscious  between  the  fits, 
and,  though  dazed,  she  was  able  to  answer  questions  intelli- 


BY  PROF.  ROBERT  JARDINE.  177 

gently.  She  was  seven  and  a  half  months  pregnant.  There 
was  no  indication  of  labour.  There  was  a  very  faint  trace  of 
albumen  in  the  urine,  but  no  oedema. 

At  5  p.m.,  2  J  pints  of  saline  solution  were  infused  into  the 
median  basilic  vein,  and  7  grains  of  calomel  followed  by 
magnesium  sulphate  were  given  and  £  gr.  of  morphia 
hypodermically.     Four  fits  occurred  before  midnight. 

29th  April. — Hypodermic  injections  of  £  gr.  of  morphia 
were  given  at  1.30  a.m.  and  4.50  a.m.,  and  also  30  gr.  chloral 
and  60  gr.  of  potassium  bromide  per  rectum  at  3  p.m.,  but  the 
fits  continued.  Strychnine  ^  gr.  was  given  four-hourly. 
Twenty- three  fits  occurred  during  the  day.  At  8  p.m.,  Dr 
Kerr  performed  vagina]  Cesarean  section  and  emptied  the 
uterus. 

30  th  April. — The  patient  had  forty-two  fits. 

1st  May. — The  patient  had  nine  fits. 

2nd  May. — The  patient  had  two  fits. 

3rd  May. — The  fits  had  ceased,  but  the  patient  was  very 
delirious.  The  restlessness  and  delirium  continued  for  three 
days,  and  after  that  recovery  was  rapid. 

It  will  be  noticed  that  the  greatest  number  of  fits  occurred 
on  the  day  after  delivery.  There  were  102  fits  in  all.  The 
case  might  be  termed  one  of  the  status  epileptic  us.  The 
fits  first  began  during  pregnancy,  so  that  according  to  Turner's 
classification  pregnancy  would  be  given  as  the  original  cause. 

Case  III. — Mrs  M.  S.,  set.  21,  iii.-para,  was  transferred  to 
the  Maternity  Hospital  from  the  Eoyal  Infirmary,  where  she 
had  been  under  treatment  for  epilepsy  for  some  weeks. 

Her  mother  was  eight  years  ago  confined  for  some  time  in 
an  asylum.  There  is  no  other  history  of  mental  disease  in  the 
family.     The  patient's  two  children  are  alive  and  healthy. 

The  patient  states  that  as  a  girl  she  enjoyed  good  health, 
but  her  parents  have  told  her  that  she  had  convulsions  when 

M 


178  EPILEPSY  AND   THE    STATUS    EPILEPTICUS, 

she  was  12  years  old.  She  has  no  recollection  of  them.  She 
was  married  four  years  ago,  and  her  first  child  was  born  in 
June  1904.  When  six  months  pregnant  she  began  to  take  fits, 
and  as  pregnancy  advanced  they  became  more  frequent,  two 
or  three  a  week.  Just  before  labour  they  become  much  more 
frequent.  She  says  she  was  unconscious  during  the  labour,  and 
for  a  couple  of  hours  afterwards.  She  had  about  two  fits  a 
week  during  the  puerperium.     She  could  not  nurse  her  baby. 

During  the  second  pregnancy  she  had  about  three  fits  per 
week.  The  child  was  born  in  December  1905,  at  full  term. 
The  patient  was  again  unconscious  during  the  labour.  As  on 
the  first  occasion,  a  midwife  attended. 

The  third,  present,  pregnancy  began  about  seven  months 
ago.  Between  the  second  and  third  pregnancies  she  had  had  about 
three  fits  a  week.  About  seven  weeks  before  admission  to  the 
Maternity  Hospital  the  fits  became  more  frequent,  and  she 
fell  and  injured  her  face  during  an  attack.  She  was  admitted 
to  the  Koyal  Infimary,  and  after  four  weeks'  treatment  in  the 
Infirmary  the  fits  ceased.  She  had  four  fits  on  the  day 
of  admission.  She  had  never  had  any  treatment  for  the  fits 
prior  to  this.  She  was  transferred  to  the  Maternity  Hospital, 
as  a  slight  vaginal  discharge  of  blood  had  commenced. 

There  was  no  indication  of  labour;  the  urine  contained  a 
trace  of  albumen ;  the  bromide  mixture  of  15  gr.  doses  thrice 
daily  was  continued. 

Two  days  after  admission  labour  came  on,  and  a  premature 
female  child  (3  lbs.)  was  born  alive,  but  only  lived  five  hours. 
There  were  no  fits  during  the  labour,  and  there  was  only  a 
very  slight  one  in  the  puerperium,  on  the  first  day  she  was 
allowed  out  of  bed. 

The  patient  stated  that  she  never  had  any  warning  of  an 
attack,  and  she  was  usually  unconscious  for  some  hours  after  a 
seizure. 

In  this  case  there  is  the  history  of  convulsions  at  the  age 


BY  PROF.  ROBERT  JARDINE.  179 

of  12,  so  that  there  was  a  predisposition,  but  pregnancy  was 
the  exciting  cause.  In  both  of  these  cases  there  was  a  trace  of 
albumen  in  the  urine. 

Case  IV. — Mrs  B.,  v.-para,  set.  26. 

The  patient's  mother  committed  suicide,  after  a  former 
unsuccessful  attempt,  by  eating  rat  poison.  Of  her  father's 
brothers  one  died  in  an  asylum  two  years  ago,  and  another 
is  in  an  asylum  at  present. 

At  the  time  of  her  mother's  death  she  was  ten  months  old, 
and  was  being  nursed  by  her  mother.  Shortly  afterwards  she 
is  said  to  have  begun  to  take  convulsions,  and  she  can 
remember  having  had  convulsions  as  a  child.  After  the  age  of 
13,  the  attacks  were  not  always  of  a  convulsive  nature.  She 
sometimes  lost  consciousness,  but  did  not  struggle.  Her 
friends  informed  her  that  in  some  of  the  attacks  she  acted 
and  spoke  in  an  unusual  way,  but  she  has  no  recollection  of 
this. 

She  was  married  seven  years  ago,  and  since  marriage  the 
attacks  have  never  been  convulsive,  but  have  consisted  of  loss 
of  consciousness,  with  strange  actions  or  remarks.  She  is  now 
pregnant  for  the  fifth  time.  One  of  the  previous  pregnancies 
was  a  twin  pregnancy.  One  of  the  twins  died  at  the  age  of 
three  and  a  half  months,  but  all  the  other  children  are  alive  and 
in  good  health,  except  one  which  is  rickety.  Her  labours  have 
been  slow  but  natural.  During  pregnancy  the  attacks  have  always 
been  much  less  frequent  than  at  other  times.  When  she  was 
nursing,  the  attacks  were  more  frequent — about  once  a 
fortnight. 

The  labour  was  natural,  and  the  patient  had  no  attacks 
while  in  hospital. 

In  this  case  pregnancy  seems  to  have  had  a  beneficial  effect 
on  the  attacks,  but  it  will  be  noticed  that  the  attacks  were  most 
frequent   during  lactation.      In  this   case   there   would   be   a 


180  EPILEPSY  AND   THE   STATUS   EPILEPTICUS, 

strong  hereditary  predisposition.     So  far,  the  children  show  no 
tendency  to  neurotic  attacks.] 

I  am  indebted  to  my  residents,  Drs  Melson  and  Walker, 
for  the  careful  notes  of  these  cases,  and  to  Dr  Carstairs 
Douglas  for  the  post-mortem  reports. 


Dr  Ritchie  said  they  owed  a  deep  debt  of  gratitude  to 
Prof.  Jardine  for  having  submitted  so  very  interesting  a  record 
of  the  case.  He  agreed  with  Dr  Jardine  that  if  one  obtained 
a  history  of  pre-existing  fits,  one  was  justified  in  diagnosing 
epilepsy  in  that  particular  case;  and  that  if  there  was  no 
previous  history  of  fits,  then  the  case  was  one  of  puerperal 
eclampsia.  He  had  had  a  good  many  cases  of  puerperal 
eclampsia,  but  in  none  of  the  cases  was  there  afterwards  a 
development  of  epilepsy.  As  to  treatment,  if  one  diagnosed 
epilepsy,  the  treatment  was  that  for  epilepsy ;  one  would  not 
expect  in  such  a  case  to  find  benefit  from  the  treatment  which 
is  necessary  for  puerperal  eclampsia. 

Dr  Haultain  said  he  could  only  follow  suit  to  what  Dr 
Eitchie  had  said.  The  question  of  epilepsy  was  a  subject  of 
very  great  interest  to  him,  as  he  had  had  a  considerable 
experience  in  the  subject  both  in  the  Maternity  Hospital  and 
in  consulting  practice.  He  was  only  sorry  the  subject  had 
been  sprung  on  them,  as  it  were,  when  otherwise  he  might  have 
been  able  to  have  gone  over  some  notes  of  cases  he  had  seen. 
On  a  haphazard  recollection  he  would  divide  epilepsy  in  preg- 
nancy into  two  great  groups — (1)  where  previously  there  had  been 
epilepsy,  and  (2)  where  there  had  not  previously  been  epilepsy. 
In  the  first  group  his  experience  seemed  to  show  that  the  effect 
of  pregnancy  was  most  irregular.  In  several  cases  pregnancy 
had  absolutely  no  effect  at  all  upon  the  disease.     In  another 


BY  PROF.  ROBERT  JARDINE.  181 

set  of  cases  the  condition  was  exaggerated.  In  two  cases 
before  his  mind,  one  was  in  a  condition  of  status  epilepticus. 
She  was  from  five  to  six  months  pregnant.  He  decided  to 
procure  abortion,  and  did  so,  but  in  spite  of  his  efforts  the 
patient  died.  In  the  second  case  the  patient  was  having  an 
exacerbation  of  fits,  and  from  previous  experience  he  thought 
the  pregnancy  should  be  ended.  Abortion  was  procured ;  the 
patient  survived,  but  lapsed  into  the  old  condition — having  fits 
occasionally,  but  in  no  way  exaggerated.  There  was  a  third 
set  of  cases  where  undoubtedly  epileptic  fits  seemed  to  be  dimin- 
ished. He  had  read  of,  and  thought  he  had  seen  cases  where 
the  presence  of  pregnancy  seemed  to  alleviate  the  tendency 
instead  of  exaggerating  it.  As  to  cases  where  epilepsy  first 
commenced  during  pregnancy,  others  of  course  brought  out 
the  question  of  the  differential  diagnosis  between  epilepsy  and 
eclampsia.  There  was  no  doubt  that  he  was  in  accord  with 
what  Dr  Jardine  had  said  regarding  the  question  of  epilepsy 
in  pregnancy  and  labour.  He  did  not  believe  these  were  cases 
of  eclampsia  at  all  unless  there  was  albuminuria.  He  had 
never  seen  true  eclampsia  where  there  was  not  highly 
albuminous  urine,  much  diminished  in  quantity.  He  had 
certainly  seen  one  case  where  epileptic  convulsions  developed 
during  pregnancy  and  returned  during  a  subsequent  pregnancy, 
and  in  the  interval  there  were  no  fits  at  all.  Again,  in  another 
case  where  the  patient  had  undoubtedly  puerperal  eclampsia, 
highly  albuminous  urine  diminished  in  amount  after  the 
confinement  was  over ;  in  eight  to  ten  days  she  again  took  fits 
at  a  time  when  there  was  no  albumen  in  the  urine.  This  case 
temporarily  upset  his  ideas  on  the  subject  of  puerperal  eclampsia 
and  albuminuria,  and  he  thought  the  case  was  one  of  epilepsy ; 
and  so  it  turned  out  to  be,  as  the  patient  had  taken  fits  several 
times  since,  independently  of  pregnancy.  The  origin  had  been 
with  puerperal  eclampsia,  and  had  remained  as  epilepsy  after- 
wards, showing  (he  difficult  problems  there  were  to  be  considered. 


182  EPILEPSY   AND   THE   STATUS    EPILEPTICUS, 

One  would  expect  the  condition  of  epilepsy  to  be  aggravated  by- 
pregnancy — a  time  when  there  is  a  toxaemic  condition ;  yet,  in 
spite  of  this,  epilepsy  in  some  cases  is  not  so  virulent  as 
before,  and  it  therefore  seems  that  we  have  nothing  to  prove 
either  in  one  thing  or  another  as  to  the  effect  of  pregnancy 
upon  epilepsy.  As  to  treatment  and  the  question  of  marriage. 
People  who  had  epilepsy  should  never  marry  under  any  cir- 
cumstances, on  account  of  the  hereditary  transmission  of  the 
disease.  If  fits  should  become  aggravated,  the  uterus  should  be 
emptied  to  prevent  any  condition  of  status  epilepticus  occurring, 
or  even  the  undermining  of  the  mental  condition  from  frequent 
convulsions,  As  to  the  treatment  by  strychnine,  it  seemed  a 
somewhat  radical  measure. 

Professor  Jardine  here  explained  that  strychnine  was  given 
to  keep  the  patient  alive. 

Dr  Haig  Ferguson  had  very  little  to  add  but  to  convey  his 
thanks  to  Professor  Jardine  for  his  interesting  paper.  Both  Dr 
Jardine  and  Dr  Haultain  had  stated  that  they  had  never  seen 
cases  of  eclampsia  where  there  was  no  albumen  in  the  urine. 
He  had  strong  and  good  grounds  for  believing  that  eclampsia 
could  exist  without  any  albuminuria.  What  was  more  im- 
portant was  the  question  of  the  diminution  in  urea.  He  had 
seen  cases  of  typical  eclampsia  where  to  begin  with  there  had 
been  no  albuminuria,  but  where  the  amount  of  urea  was  con- 
siderably diminished.  He  had  always  been  of  the  belief  that 
puerperal  convulsions  should  not  be  regarded  as  epileptic  if 
the  patient  had  no  previous  history  of  epilepsy,  though  a  patient 
with  a  previous  history  of  epilepsy  might  take  puerperal  con- 
vulsions. One  case  occurred  to  his  mind,  where  the  woman  in 
her  first  pregnancy  took  a  large  number  of  convulsions  which 
were  supposed  to  be  eclamptic.  There  was  no  diminution  in 
the  urea  and  no  albuminuria.  On  making  a  close  inquiry  into 
the  previous  history,  it  was  discovered  that  the  woman  had  had 
attacks  of  petit  mat  at  every  menstrual  period.     In  this  case 


BY   PROF.  ROBERT  JARDINE.  183 

the  condition  of  epilepsy  had  been  aggravated  during  pregnancy. 
He  had  never  seen  a  case  where  the  fits  were  cured  by  preg- 
nancy. All  the  cases  he  had  seen  had  appeared  to  have  had  the 
condition  somewhat  aggravated  by  the  pregnant  condition.  He 
would  say  that  any  woman  who  had  epileptic  convulsions 
during  pregnancy  had  had  epilepsy  on  some  previous  occasion. 
They  were  greatly  indebted  to  Dr  Jardine  for  his  paper. 

Dr  Porter  had  had  one  case,  eight  months  ago,  a  primipara, 
19  years  of  age,  who  had  had  regular  epileptic  seizures, 
aggravated  at  every  menstrual  period.  At  the  seventh  month  of 
pregnancy  she  had  developed  slight  albuminuria.  The  labour 
was  quite  normal.  She  had  two  fits  about  the  fifteenth  day  of 
the  puerperium,  which  were  easily  controlled  by  bromide. 
The  child  had  been  delivered  naturally. 

The  President  said  his  experience  was  along  the  lines  of 
these  mentioned.  He  remembered  one  case  at  the  Dispensary 
where  the  patient  had  epilepsy  except  during  the  times  of 
pregnancy,  the  epilepsy  returning  again  a  month  after  the 
pregnancy  was  over.  He  afterwards  came  across  one  or  two 
other  cases  where  this  did  not  apply,  and  he  had  had  quite  a 
number  of  interesting  cases  at  the  Maternity  Hospital.  The 
main  result  of  them  had  just  been  that  some  were  better  during 
pregnancy,  and  some  were  worse.  Some  were  free  during 
pregnancy,  and  some  were  free  except  at  the  time  of  pregnancy. 
There  were  not  many  where  there  was  any  special  development 
during  pregnancy.  With  regard  to  the  relationship  of  eclampsia 
and  epilepsy,  they  must  come  to  the  conclusion  that  the 
eclampsia  we  had  in  this  country  differed  in  some  way  from 
that  in  America  and  other  parts  of  the  world.  Americans 
constantly  assured  him  that  they  had  a  number  of  cases  where 
there  was  no  albumen  in  the  urine,  and  said  that  a  great 
number  of  their  cases  were  nervous,  and  to  be  included  under 
epilepsy  and  hystero-epilepsy  rather  than  eclampsia. 

Prof.  Jardine,  in  reply,  said  there  was  a  fair  amount  of  albumi- 


184  BILATERAL  OVARIAN  DERMOID   TUMOURS, 

nuria  in  all  cases  of  eclampsia,  and  also  diminution  of  urea. 
He  wished  some  of  those  accustomed  to  deal  with  such  cases 
in  asylums  had  been  present  at  the  discussion.  It  was  an 
extremely  difficult  thing  to  decide  about  the  .  question  of 
epilepsy  in  connection  with  pregnancy.  They  knew  that  the 
effect  of  pregnancy  on  the  nervous  system  of  women  varied 
very  much,  and  they  could  imagine  that  the  same  differences 
would  show  themselves  in  those  who  were  the  subject  of 
epilepsy.  He  had  only  had  one  or  two  cases  of  epilepsy  where 
the  patient  had  seemed  to  be  better  during  pregnancy.  Last 
year  he  had  reported  a  case  of  recovery  after  two  hundred  fits. 
He  had  looked  on  that  case  as  eclampsia,  but  it  might  have 
been  epilepsy,  although  she  had  never  had  a  fit  before. 


VI.  BILATERAL  OVARIAN  DERMOID  TUMOURS, 
COMPLICATING  PREGNANCY. 

By  Dr  Malcolm  Campbell. 

While  the  keen  attention  which  has  recently  been  directed  to 
the  identification  of  endotheliomata  has  undoubtedly  upset  the 
recognised  order  of  relative  frequency  among  ovarian  tumours, 
yet  dermoids  must  always,  from  their  nature,  continue  to 
maintain  their  position  as  the  most  interesting  form  of  tumour 
with  which  the  gynaecologist  comes  in  contact.  Though 
dermoids  can  no  longer  be  regarded  as  rare  tumours,  yet  they 
undoubtedly  are  still  relatively  rare.  In  the  seven  volumes  of 
Transactions  which  this  Society  has  issued  during  the  present 
century,  there  are  records  of  only  fifteen  dermoids  having  been 
exhibited.  A  liberal  computation  of  the  frequency  of  dermoids 
puts  them  down  as  from  3  to  4  per  cent,  of  all  ovarian  tumours. 
Of  all  forms  of  ovarian  tumour,  the  dermoid  is  the  one 
most  frequently  associated  with  pregnancy.  M'Kerron  has 
tabulated  113  cases   in   which   ovarian   tumours   complicated 


BY  DR  MALCOLM  CAMPBELL.  185 

pregnancy — of  this  series  no  fewer  than  forty-six  were  dermoids. 
Besides  being  the  type  of  ovarian  tumour  which  most  frequently 
complicates  pregnancy,  the  dermoid  is  the  most  dangerous,  for 
in  this  series  of  forty-six  cases  there  were  eighteen  maternal 
deaths  due  to  injury  of  the  tumour  during  labour. 

While  dermoids,  both  as  ovarian  tumours  and  in  their 
relationship  to  pregnancy  and  parturition,  offer  an  interesting 
field  of  study,  the  subject  of  bilateral  ovarian  dermoids  is  even 
more  interesting.  In  regard  to  the  frequency  of  the  condition, 
the  experience  of  gynaecologists  varies  within  wide  limits. 
Howard  Kelly,  in  a  series  of  eighty-seven  cases  in  which  he 
operated  for  ovarian  dermoids,  only  found  the  condition  bi- 
lateral in  one  instance.  Munde,  in  a  series  of  fifteen  operations 
for  dermoids,  found  the  condition  bilateral  in  three  cases. 
G-ebhard,  out  of  107  cases,  found  bilateral  dermoids  no  fewer 
than  sixteen  times. 

In  1902,  Loewy  and  Paul  Gueniot  published  a  paper  on 
the  subjeet  of  bilateral  dermoids,  in  which  they  were  able  to 
collect  ninety-eight  cases.  In  thirty  of  these  cases  the  patient's 
reproductive  history  was  given.  In  five  patients  there  was  a 
history  of  one  pregnancy,  while  five  others  had  each  given 
birth  to  two  children.  The  other  cases  had  all  had  more  than 
three  children,  and  in  one  case  there  was  a  history  of  seven 
full-time  pregnancies  and  five  abortions ;  while  another  patient, 
prior  to  operation,  had  borne  twelve  living  children,  and  in 
addition  had  one  abortion. 

I  have  been  able  to  find  references  to  only  nine  cases  in 
which  bilateral  ovarian  dermoids  were  removed  during  preg- 
nancy ;  and  I  have  also  found  the  notes  of  a  case,  published  by 
F.  Page,  who  operated  on  a  patient  for  peritonitis,  two  and  a 
half  months  after  labour, — when  the  abdomen  was  opened, 
bilateral  ovarian  dermoids  were  found. 

Of  the  nine  double  ovariotomies  for  dermoids  during 
pregnancy,  I  have  only  been  able  to  see  the  original  communi- 


186  BILATERAL  OVARIAN   DERMOID   TUMOURS, 

cation  in  one  case,  viz.,  that  of  Knowsley  Thornton,  in  which, 
on  4th  February  1886,  he  removed  bilateral  dermoids  from  a 
patient  who  was  delivered  of  a  full-term  foetus  on  23rd  June  of 
the  same  year. 

Though  the  preceding  notes  can  in  no  sense  be  regarded 
as  a  review  of  the  literature  of  the  subject,  the  figures  I  have 
quoted  seem  to  me  to  amply  justify  my  bringing  the  following 
case  to  the  notice  of  the  Society : — 

The  patient,  Mrs  F.,  set.  32,  was  admitted  to  Dr  Brewis's 
ward  on  2nd  June  1906.  She  had  been  married  twelve  years, 
and  had  five  children,  the  eldest  set.  10,  the  youngest  aet.  2 
years  and  3  months.  Beyond  some  premenstrual  dysmenorrhea 
before  marriage,  there  was  nothing  to  note  in  regard  to 
menstruation,  which  began  at  14,  was  of  twenty-eight-day 
type,  and  lasted  four  days.  There  had  been  amenorrhoea  from 
March  1906. 

Before  the  onset  of  her  present  illness,  six  months  prior  to 
admission,  patient  had  enjoyed  perfect  health. 

On  admission,  the  patient  complained  of  pain  in  the  right 
side,  which  she  stated  went  round  to  her  back.  The  onset  of 
the  pain  in  January  1906  was  sudden,  and  the  pain  so  severe 
that  patient  had  to  remain  in  bed  for  a  week,  and  was  only 
able  to  lie  on  her  left  side.  During  this  attack  there  was 
some  vomiting.  There  was  no  vaginal  discharge.  Since  the 
initial  attack  there  had  been  several  returns  of  the  pain  at 
intervals.  The  pain  came  on  without  any  discoverable  cause, 
lasted  for  about  an  hour,  and  then  passed  off.  The  pain  was 
worst  in  the  right  iliac  fossa,  then  from  there  it  radiated  to  the 
back.     She  occasionally  had  vomited  with  these  attacks. 

About  three  months  before  admission,  patient  first  noticed  a 
swelling  on  the  right  side  of  the  abdomen.  The  last  attack  of 
pain  occurred  about  a  week  before  admission. 

Physical    Examination. — The    abdomen    was    seen    to    be 


BY   Dll   MALCOLM   CAMPBELL.  187 

slightly  distended  by  a  swelling  passing  from  the  right  lumbar 
region  to  midway  between  the  sternum  and  the  umbilicus. 
This  swelling  moved  freely  with  the  respiratory  movements. 
On  palpation,  a  tumour  was  found  extending  from  the  mid-line 
to  the  anterior  axillary  line  on  the  right  side.  The  tumour, 
which  was  flattened  antero-posteriorly,  seemed  to  be  disc-shaped, 
and  was  about  4  inches  in  diameter.  The  tumour  was  not 
sensitive  on  palpation.  It  was  not  uniform  in  consistence,  and 
could  be  moved  freely.  If  pulled  upon,  a  tense  band  could  be 
felt  running  down  into  the  pelvis.  The  uterus  could  be  felt  in 
the  hypogastric  region.  There  was  no  free  fluid,  in  the  abdomen. 
On  vaginal  examination  the  uterus  was  found  enlarged,  and 
undergoing  rhythmic  changes  in  consistence.  There  was  marked 
pulsation  in  both  lateral  fornices.  In  the  left  lateral  fornix, 
posteriorly,  a  hard  irregular  non-sensitive  body  about  the  size 
of  a  hen's  egg  could  be  felt ;  this  was  evidently  the  displaced 
left  ovary.     The  right  ovary  could  not  be  felt. 

On  6  th  June  the  abdomen  was  opened,  and  the  tumour 
above  described  was  found  to  be  an  ovarian  tumour  with  a  very 
long  pedicle,  growing  from  the  right  side :  it  was  removed  in 
the  usual  way.  On  removal  it  was  about  the  size  of  a  foetal 
skull,  and  on  being  incised  was  seen  to  be  a  dermoid  tumour 
containing  sebaceous  matter,  hair,  and  teeth. 

The  left  ovary  was  examined;  an  attempt  was  made  to 
resect  this  ovary,  in  order  to  conserve  for  the  patient  some 
ovarian  tissue ;  as  this,  however,  was  found  impracticable,  the 
whole  ovary  was  removed.  On  examination,  it  was  found 
also  to  be  a  dermoid  cyst  containing  sebaceous  material  and 
hair. 

The  patient  made  a  most  satisfactory  recovery.  Before 
leaving  hospital,  a  month  after  the  operation,  patient  felt  foetal 
movements,  but  on  auscultation  no  festal  heart  sounds  could  be 
heard. 

Since    leaving    hospital    on    7th    July,    patient  has  beon 


188  BILATERAL  OVARIAN  DERMOID   TUMOURS, 

perfectly  well  She  was  delivered  of  a  living  child  on  9th 
December. 

The  fact  that  both  ovaries  were  removed  at  the  end  of  the 
third  month  of  gestation  adds  another  point  of  interest  to  the 
case,  for  Heil  has  shown  that  abortion  is  most  likely  to  occur 
in  the  cases  in  which  the  corpus  luteum  is  removed  before  the 
fourth  month. 

In  regard  to  the  endeavour  to  conserve  a  portion  of  ovarian 
tissue,  it  is  interesting  to  note  that  Matthei,  Schroeder,  and 
Terrier  have  all  recorded  cases  in  which  pregnancy  followed 
the  removal  of  bilateral  ovarian  dermoids,  where  it  had  been 
found  possible  to  conserve  some  ovarian  tissue. 

In  conclusion,  I  should  like  to  express  my  thanks  to  Dr 
Brewis  for  permission  to  communicate  this  case,  and  to  Dr 
McMaster  for  some  notes  on  the  case. 


Dr  Haultain  was  much  interested  in  the  case  Dr  Campbell 
reported.  Personally,  he  had  not  had  any  experience  of  remov- 
ing bilateral  dermoids,  though  on  several  occasions  he  had 
removed  a  dermoid  from  one  side.  In  this  connection  there 
was  an  interesting  case  of  a  person  he  saw  four  or  five  years 
ago,  in  whom  he  had  diagnosed  ovaritis.  The  patient  suffered 
a  very  great  deal  of  pain,  and  said  life  was  not  worth  living. 
He  had  no  room  for  her  in  his  home  at  that  time,  but  sent 
for  her  to  come  in  three  weeks  later,  and  without  examining 
again,  proceeded  to  operate.  He  thought  at  the  time  of  opera- 
tion that  the  uterus  was  a  little  large  and  purplish  in  colour, 
but  removed  the  ovaries.  The  patient  was  delivered  at  full 
time  of  a  healthy  child.  This  case  showed  that  even  at  that 
early  date  removal  of  the  ovaries  seemed  to  have  no  effect  on 
the  growth  of  the  foetus.  At  the  present  time  there  were  a 
large  number  of  researches  on  the  corpus  luteum  of  pregnancy. 
So  far,  they  seemed  to  show  the  corpus  luteum  had  very  little  to 


BY  DR  MALCOLM  CAMPBELL.  189 

do  with  pregnancy.     He  thanked  Dr  Malcolm   Campbell   for 
having  brought  forward  the  case. 

The  President  had  not  met  with  a  case  of  double  dermoid, 
but  had  had  four  or  five  cases  of  single.  As  to  ovarian  secre- 
tion, the  theory  which  had  always  seemed  to  him  to  be  an 
extraordinary  one,  was  that  the  corpus  luteum  was  the  secretory 
gland  of  the  ovary  travelling  about  from  different  parts  of  the 
ovary  in  different  months,  simply  being  functional  in  one  part 
for  one  month,  and  then  in  another.  If  one  looked  at  it  from 
the  point  of  view  of  luteum,  what  was  luteum?  It  was  a 
perfectly  innocuous  thing,  and  going  on  that  line  he  had 
always  been  sceptical  about  theories  brought  forward  as  to  the 
curative  value  of  lutein  and  the  corpus  luteum. 

Dr  Malcolm  Campbell,  in  reply,  said  he  had  kept  purposely 
off  the  corpus  luteum.  But  although,  as  some  maintained,  the 
corpus  luteum  might  do  nothing,  it  should  be  treated  with 
some  respect,  and  left  where  possible. 


Meeting  VII. — June  12,  1907. 
•     Dr  J.  W.  Ballantyne,  President,  in  the  Chair. 

I.  Dr  Brewis  exhibited — (a)  A  full-sized  crochet-needle, 
removed  from  the  right  iliac  region  of  a  patient  who  had 
pushed  a  needle  into  the  vagina  and  lost  it.  Five  weeks  later, 
on  admission,  a  hard  parametric  mass  was  felt  anterior  to  the 
supravaginal  part  of  the  cervix ;  and  to  the  right,  about  an  inch 
above  the  middle  of  Poupart's  ligament,  there  was  a  projecting 
mass  which  was  suspected  to  contain  one  end  of  the  lost 
needle.  On  cutting  down  on  the  mass,  this  was  found  to  be 
the  case,  and  the  needle  was  extracted. 

(6)  A   large   slough    from    the   interior   of    the    uterus, 


190  EXHIBITION  OF  SPECIMENS. 

produced  by  the  use  of  chloride  of  zinc  in  a  case  of  inoperable 
carcinoma.  On  microscopic  examination,  the  specimen  was  found 
to  consist  of  vascular  fibrous  tissue  and  unstriped  muscle. 
These  were  both  necrotic  in  parts  and  infiltrated  with  leucocytes, 
while  there  was  also  some  infiltration  of  epithelial  cells,  suggest- 
ing the  presence  of  carcinoma.  The  slough  was  fully  an  inch  in 
diameter,  showing  that  destruction  of  the  uterine  wall  by  the 
zinc  had  been  extensive. 

(c)  A  cystic  swelling,  somewhat  pear-shaped,  with  a  long 
axis  of  8 J  inches,  and  a  circumference  of  11  inches  at  the 
broad  end  of  the  pear.  It  was  a  monocyst,  formed  by  the 
junction  of  cystic  right  and  left  Fallopian  tubes,  and  a  dis- 
tended and  unrecognisable  right  ovary.  The  contents  were 
caseous-like,  and  consisted  of  fatty  matter  and  cholesterin 
crystals,  while  on  certain  parts  of  the  walls,  internally,  were 
deposits  of  calcareous  matter. 

(d)  Uterus,  containing  a  large  submucous  fibroid, 
attached  by  a  broad  pedicle  to  the  fundus.  The  uterus  was 
removed  by  supravaginal  hysterectomy  along  with  both  ovaries, 
one  of  which  was  converted  into  a  monocyst  the  size  of  a 
tennis  ball,  while  the  other  contained  a  haematoma. 

(e)  Large  soft  edematous  fibroid  tumour,  removed  by 
hysterectomy.  The  tumour  presented  physical  signs  closely 
resembling  a  six  months'  pregnant  uterus. 

(/)  Uterus  removed  by  vaginal  hysterectomy  for  bleeding, 
and,  from  the  same  patient,  a  hematoma  of  the  left  broad 
ligament. 

II.  Br  Haig  Ferguson  showed — (a)  extra-uterine  preg- 
nancy, nearly  four  months'  duration.  The  tube  had  ruptured 
in  the  country.  When  seen  in  town,  there  was  a  swelling 
behind  the  uterus,  and  extending  well  up  into  the  abdomen, 
and  one  waited  to  see  if  it  was  growing,  and  as  it  was  found 
to  be  rapidly  growing,  it  was  removed  by  abdominal  section. 
The  tube  had  ruptured  into  the  cavity  of  the  broad  ligament. 


EXHIBITION   OF   SPECIMENS,   ETC.  191 

(b)  Specimen  from  patient,  a  multipara,  aet.  44,  suffering 
from  irregular  haemorrhages.  The  uterus  was  scraped  7th  June, 
and  the  pathologist's  report  was  as  follows : — "  Gland  tubes  of 
highly  irregular  shape,  lined  with  columnar  cells,  irregular  in 
arrangement,  forming  numerous  papillae  within  the  lamina  of 
the  tubes.  The  epithelial  formation  is  disproportionately  great 
in  comparison  with  the  connective  tissue.  A  specimen  of  the 
early  stage  of  a  rapidly  developing  papillary  adeno-carcinoma 
of  the  body  of  the  uterus."  The  uterus  was  removed  by  vaginal 
hysterectomy.  This  was  the  fifth  case  of  malignant  fundus  he 
had  operated  upon  in  the  last  year  by  vaginal  hysterectomy, 
with  satisfactory  results. 

III.  The  President  showed  a  photograph  of  a  native  mid- 
wife of  Nazareth,  with  a  trained  midwife  from  this  country 
standing  beside  her. 


IV.  SIX  CASES  OF  VAGINAL  CESAREAN  SECTION. 

By  N.  T.  Brewis,  M.B.,  F.R.C.S.E.,  Gynaecologist,  Royal  Infirmary, 

Edinburgh. 

When  I  listened  to  Dr  Munro  Kerr's  paper  delivered  before 
the  Society  some  three  years  ago,  in  which  he  described  in  a 
very  lucid  manner  the  operation  of  vaginal  Caesarean  section, 
introduced  by  Diihrssen,  it  brought  to  my  mind  more  than  one 
case  where,  had  I  been  conversant  with  the  procedure,  I  would 
have  been  glad  to  take  advantage  of  it.  One  case  particularly 
I  recalled  of  a  patient  in  the  country,  four  months  pregnant, 
brought  to  the  point  of  death  by  severe  and  uncontrollable 
vomiting,  whose  cervix  was  so  rigid  that  Bossi's  dilator  was 
unable  to  effect  dilatation  of  the  internal  os  to  any  extent,  and 
the  foetus  and  placenta  had  to  be  extracted  bit  by  bit  through 
an  opening  no  bigger  than  a  keyhole.  When  I  considered  that 
the  time,  energy,  and  force  spent  in  the  attempt  to  overcome 
the  resistance  could  have  been  saved  by  a  few  cuts  with  the 


192  SIX  CASES   OF  VAGINAL   CESAREAN   SECTION, 

scissors,  the  value  of  Diihrssen's  operation  came  home  to  me 
and  made  me  determine  to  practise  the  method  on  the  first 
suitable  occasion. 

The  opportunity  soon  occurred.  The  following  notes  of  my 
first  case  were  kindly  furnished  me  by  the  patient's  medical 
attendant,  Dr  Henderson,  Kirkcaldy  : — 

Case  I. —  Vomiting  of  Pregnancy.  —  "Mrs  H.,  aet.  30. 
Previous  and  family  history  good.  In  January  1903,  when  two 
months  pregnant  and  in  her  first  pregnancy,  she  began  to 
suffer  from  severe  and  intractable  vomiting.  The  usual 
medicinal  remedies  were  of  no  avail.  Eectal  feeding  had  to  be 
adopted.  Operative  interference  was  seriously  considered, 
when  she  spontaneously  aborted.     She  made  a  rapid  recovery. 

"  On  29th  November  1905,  when  three  months  pregnant 
and  in  her  second  pregnancy,  she  was  again  prostrated  by 
severe  vomiting.  As  before,  medicinal  remedies  were  found  of 
no  avail.  All  nourishment  given  by  the  mouth  was  returned. 
The  vomiting  and  retching  was  persistent,  and  independent  of 
the  taking  of  food  or  medicine.  On  6th  December  1905,  Mr 
Brewis  dilated  the  cervix  under  chloroform.  The  vomiting 
gradually  subsided,  till  in  ten  days'  time  the  patient  was  able 
to  retain  and  enjoy  food,  and  was  up  and  about. 

"  On  1st  February  1906,  vomiting  again  set  in,  producing  very 
rapidly  great  prostration,  emaciation,  and  dusky  complexion. 
The  patient  presented  the  appearance  of  one  overwhelmed 
with  a  profound  toxaemia.  On  3rd  February  her  condition  was 
desperate.  On  that  day  Mr  Brewis  performed  vaginal  Cesarean 
section.  She  had  slight  vomiting  for  two  or  three  anxious  days, 
and  then  absolute  recovery." 

I  operated  twice  on  this  patient — first  in  November,  for 
severe  vomiting,  when  the  patient  was  three  months  pregnant. 
Though  the  vomiting  was  severe  the  patient  was  not  seriously 
ill,  and  I  performed  the  operation  which  I   had    found   most 


BY  DR   N.    T.    BREWIS.  193 

useful  in  those  cases,  viz.,  dilatation  of  the  cervix,  followed  by 
the  administration  of  chloral  per  rectum. 

At  my  second  visit,  three  months  later,  the  patient's  life 
was  in  danger  so  imminent  that  I  considered  it  indicated  to 
empty  the  uterus  as  quickly  as  possible. 

A  month  later  I  had  another  opportunity  of  putting  the 
operation  to  the  test  in  a  case  equally  serious,  but  belonging  to 
quite  a  different  category. 

Case  II. — Eclampsia.  Delivery  by  vaginal  Cesarean  section, 
at  seven  and  a  half  months,  of  a  living  child,  followed  by  complete 
recovery  of  mother. — Mrs  B.,  set.  26,  was  married  in  November 
1905,  and  came  under  my  care  on  20th  March  1906,  when  she 
was  six  months  pregnant.  The  following  is  the  history  of  the 
case : — A  week  before  admission  she  first  noticed  her  feet 
swollen.  The  swelling  was  slight,  and  not  painful.  A  few  days 
later  her  face  and  hands  also  swelled,  and  she  felt  pain  low 
down  across  her  back.  About  three  weeks  ago  she  had  a  bad 
cold  and  cough.  This  condition  lasted  a  week,  and  was  almost 
like  whooping-cough,  and  prevented  sleep.  A  week  before 
admission  she  got  cold  again,  and  had  a  slight  cough  on 
admission.  Her  last  period  began  on  5th  November,  and  lasted 
three  days. 

She  had  suffered  from  headaches,  chiefly  occipital  in 
character. 

She  had  scarlet  fever  when  about  six  years  old.  There  was 
no  history  of  kidney  trouble. 

On  admission,  the  face  was  puffy,  especially  the  eyelids. 
There  was  slight  oedema  of  both  hands.  Both  feet  and  legs 
were  oedematous,  the  right  ankle  more  so  than  the  left. 

She  suffered  from  breathlessness  on  exertion.  The  pulse 
was  regular  and  of  high  tension. 

The  thyroid  gland  was  enlarged.  The  breathing  was  harsh, 
but  there  were  no  accompaniments. 

N 


194  SIX   CASES   OF  VAGINAL   CESAREAN   SECTION, 

Albumen  was  present  in  the  urine  in  large  quantity. 

Two  days  before  operation  patient  had  a  fit,  followed  by  a 
semi-conscious  condition.  On  the  next  day  she  had  two  fits. 
On  the  morning  of  the  day  of  operation  she  had  a  fit,  after 
which  she  remained  in  a  semi-unconscious  condition  all  day. 
No  urine  was  passed  that  day.  The  operation  was  performed 
in  the  evening. 

The  operation  is  as  follows : — 

The  patient  was  put  in  the  lithotomy  position,  and  after  the 
customary  preparation  for  major  pelvic  operations  the  vaginal 
portion  of  the  cervix  was  drawn  down  to  the  vulva. 

The  anterior  vaginal  wall  was  divided  transversely  im- 
mediately above  the  external  os,  and  along  with  the  bladder 
was  pushed  upwards.  The  anterior  surface  of  the  cervix  was 
cleared  in  this  manner,  and  then  divided  vertically  in  the 
middle  line  with  scissors  for  3  or  4  inches.  The  membranes 
were  then  ruptured,  and  forceps  applied  to  the  child's  head, 
which  was  lying  in  the  most  common  position.  Gentle  traction 
was  used,  and  after  a  quarter  of  an  hour's  manipulation  the  child 
was  delivered.     The  placenta  was  expressed  a  short  time  later. 

The  cervical  incision  was  sewn  together  with  catgut.  Then 
the  anterior  wall  of  the  vagina  and  the  bladder  were  stitched 
into  position.  The  uterus  was  irrigated  with  weak  lysol 
solution,  and  the  patient  put  to  bed. 

Although  the  traction  required  was  considerable,  there  was 
no  tearing  of  the  wound  farther  up.  Probably  the  cervical 
wound  might  have  been  made  1  inch  longer  without  injury. 

The  patient,  after  a  tardy  recovery,  complicated  by  a  severe 
attack  of  broncho-pneumonia,  returned  home  on  11th  May. 
She  is  now  in  good  health.  The  child,  although  premature,  was 
by  the  aid  of  an  incubator  kept  alive,  and  though  it  had  a 
considerable  struggle  for  existence,  was  sent  home  when  about 
a  month  old.     It  is  now  a  strong  and  healthy  child. 

With  regard  to  the  applicability  of  this  operation  to  cases 


BY  DR   N.    T.    BREWIS.  195 

of  eclampsia,  I  would  say  that  if  it  is  conceded  that  in  grave 
cases  the  uterus  should  be  emptied  rapidly,  Diihrssen's  opera- 
tion, owing  to  the  safe,  simple,  and  rapid  manner  in  which  it 
can  be  performed,  is  a  most  rational  and  proper  procedure,  and 
one  which  is  much  to  be  preferred  to  the  classical  Cesarean 
section.  In  less  urgent  cases  the  slower  methods  of  dilatation 
may  still  have  a  place,  though,  if  good  results  are  to  be  got, 
I  think  the  principle  of  not  waiting  too  long  should  be  adopted. 
Statistics  show  better  results  by  this  method  than  by  any 
other.  Veit  performed  the  operation  thirty-three  times  for 
eclampsia  with  only  one  death,  and  Diihrssen  has  collected  112 
cases  having  a  mortality  of  15  per  cent. 

Case  III. — Stenosis  following  Amputation  of  the  Cervix. — 
The  patient,  Mrs  B.,  was  operated  on  by  me  in  March  1905,  for 
a  large  retroverted  uterus  and  hypertrophied  eroded  cervix. 
The  vaginal  portion  of  the  cervix  was  amputated.  The  uterus 
was  curetted  and  replaced,  and  the  round  ligaments  shortened. 

I  next  saw  the  patient  in  May  of  the  following  year,  and  she 
was  then  five  months  pregnant.  She  went  into  labour  at  end  of 
September  1906,  and  when  I  saw  her  some  waters  had  escaped, 
the  head  was  presenting ;  no  external  os  could  be  felt,  but  the 
lower  uterine  segment  was  thinned  and  spread  over  the  pre- 
senting part.  The  patient  had  suffered  from  pains  at  intervals, 
and  was  apparently  in  labour.  Eupture  of  the  extremely  thin 
uterine  segment  was  feared.  The  patient  was  prepared  for 
operation. 

A  transverse  incision  was  made  through  the  vaginal  wall  in 
front  of  the  presenting  part.  The  bladder  was  pushed  up,  and 
the  lower  uterine  segment  divided  vertically  as  high  as  the 
internal  os.  The  foetus  was  delivered  with  forceps,  and  the 
placenta  expressed.     The  patient  made  a  good  recovery. 

Case  IV. — Heart  Disease — Mitral  Stenosis  and  Incompetence, 


196  SIX   CASES   OF   VAGINAL   CESAREAN   SECTION, 

with  (Edema  of  Lungs. — Operation  performed  at  five  and  a  half 
months.  The  following  are  the  notes  which  were  kindly  given 
me  by  her  medical  attendant,  Dr  Fleming : — 

"  I  first  attended  Mrs  D.  in  June  1906,  for  cough  due  to 
slight  oedema  of  the  lungs.  Her  heart  was  dilated.  The 
impulse  was  felt  fully  1  inch  outside  the  nipple  line,  accom- 
panied by  a  thrill  due  to  mitral  obstruction  and  incompetence. 
At  intervals,  chiefly  at  night,  she  had  attacks  of  dyspnoea  and 
heart  pain.     She  was  able  to  walk  a  short  distance. 

"  She  told  me  on  the  18th  November  that  she  had  not  men- 
struated since  the  middle  of  August,  and  that  but  for  slight 
squeamishness  she  felt  nothing  wrong.  In  fact,  she  had  not 
felt  so  well  for  a  long  time.  I  had  been  called  to  see  her  at 
the  time  because  of  slight  bleeding,  probably  induced  by  being 
shaken  in  a  motor  bus.  This  was  relieved  by  a  few  days'  rest 
in  bed.  During  the  early  weeks  of  December  she  had  attacks 
of  dyspnoea  and  cardiac  pain,  and  was  put  on  inf.  digitalis — 
which  she  had  been  taking  at  intervals  since  1904 — and  tabell. 
trinitrini.  Under  this  treatment  the  cardiac  pain  diminished, 
the  pulse  got  stronger  and  more  regular,  and  she  was  able  to 
walk  better.  About  the  24th  of  December  she  went  on  a  visit 
of  three  weeks  duration  to  Glasgow,  and  while  there  had  a  bad 
attack  of  dyspnoea  and  cardiac  pain.  The  induction  of  pre- 
mature labour  was  considered  at  this  time,  but  it  was  finally 
decided  to  allow  the  pregnancy  to  go  on. 

"On  17th  January  1907,  her  heart  was  very  irregular  in 
action.  She  had  not  had  sleep  for  some  weeks  on  account  of 
the  dyspnoea  and  cardiac  pain.  There  was  oedema  of  the  lungs. 
On  the  19th  January  Dr  Brewis  came  to  see  her,  took  a  very 
grave  view  of  the  case,  and  advised  operation." 

On  admission,  the  uterus  was  found  to  be  enlarged  to  the 
size  of  a  six  months'  pregnancy.  The  cervix  was  firm  to  the 
touch. 

The  vulvar  aperture  was  enlarged  by  making  an  'incision 


BY  DK  N.   T.    BREWIS.  197 

about  f  of  an  inch  long  into  the  anterior  part  of  the  perineum. 
The  cervix  was  pulled  down,  an  incision  was  then  made  through 
the  vaginal  wall  at  the  junction  of  the  vagina  with  the  cervix 
in  front.  The  anterior  aspect  of  the  cervix  was  exposed  by 
pushing  up  the  bladder.  The  cervix  was  then  cut  open  by 
scissors  through  the  whole  length  of  the  anterior  part  until 
the  uterine  cavity  was  opened  into.  An  incision  about  \  an 
inch  long  was  made  in  front  into  the  lower  part  of  the  body  of 
the  uterus.  The  membranes  were  exposed.  These  were  ruptured, 
and  the  liquor  amnii  allowed  to  escape.  The  breech  was  found 
to  be  presenting.  The  lower  limbs  and  trunk  were  delivered, 
and  difficulty  was  experienced  with  the  after-coming  head. 
Forceps  were  applied,  and  the  head  delivered.  The  child  was 
dead.  It  was  a  well-developed  five  and  a  half  months'  foetus. 
The  placenta  was  then  separated  and  expressed.  The  incision 
into  the  anterior  and  lower  part  of  the  body  of  the  uterus  and 
the  incision  into  the  cervix  were  closed  with  interrupted  stitches 
of  strong  catgut.  The  uterine  cavity  was  washed  out  with  a 
warm  saline  douche.  The  incision  in  the  anterior  fornix  was 
closed  with  sutures  of  medium  catgut,  and  the  perineum  was 
repaired  with  a  sub-cuticular  stitch  of  medium  catgut.  A  small 
gauze  drain  was  put  into  the  cervical  canal.  Gauze  was  also 
packed  into  the  vagina  after  it  had  been  douched  with  hot 
saline. 

She  was  somewhat  breathless  for  two  days  after  the  opera- 
tion. On  the  third  day  she  was  able  to  lie  in  the  recumbent 
position.  She  went  home  on  the  16th  February  feeling  very 
well.  She  had  no  distressing  breathless  attack  after  the 
operation.  On  her  dismissal  she  was  still  cyanosed,  especially 
marked  on  her  cheeks,  ears,  nose,  and  finger  nails,  and  there 
were  fresh  small  sub-conjunctional  haemorrhages. 

It  was  evident  from  the  extreme  distress  which  this 
patient's  cardiac  condition  occasioned,  that  the  termination  of 
her  pregnancy  was  urgently  indicated,  and  the  only  question  to 


198  SIX  CASES   OF  VAGINAL  CESAREAN   SECTION, 

be  considered  was  the  method  to  be  adopted.  Her  cardiac 
condition  appeared  critical,  and  it  seemed  evident  that  the 
more  speedily  the  uterus  could  be  emptied,  the  less  would  be 
the  strain  on  the  heart,  therefore  it  was  decided  to  perform 
vaginal  Csesarean  section.     The  result  was  very  satisfactory. 

Case  V. — Haemorrhage  due  to  Premature  Separation  of  'part 
of  a  Low-Placed  Placenta — Placenta  Prwoia. — Mrs  T.,  ret.  38, 
had  been  married  sixteen  years,  and  had  six  children,  the  last 
being  born  eighteen  months  before  admission.  She  had  a 
miscarriage  at  two  and  a  half  months,  three  years  before 
admission.  She  was  admitted  on  7th  June  1906,  complaining 
of  floodings. 

At  the  beginning  of  March,  while  still  nursing  her  child, 
the  milk  ceased,  and  patient  had  a  severe  bleeding  for  a  day 
and  a  night.  She  got  up  next  day  and  felt  quite  well  till  five 
weeks  later,  when  she  had  a  second  flooding.  The  bleeding 
came  and  went  for  a  day  or  two,  and  she  was  confined  to  bed 
for  a  week.  On  getting  up  she  felt  weak  and  went  for  a 
holiday  for  a  week,  and  on  returning  home  she  again  had  red 
discharge.  The  discharge  came  on  every  night  for  two  weeks 
— not  copious,  only  coming  away  when  she  lay  down.  At  the 
end  of  two  weeks  another  flooding  took  place,  and  for  the  four 
weeks  previous  to  admission  she  had  been  confined  to  bed  with 
a  more  or  less  constant  red  discharge. 

Before  the  present  illness  her  menstrual  history  had  shown 
nothing  of  a  morbid  nature.  Her  labours  were  natural,  and 
she  had  no  serious  illness. 

On  admission,  a  tumour  was  felt  in  the  abdomen,  suggesting 
a  six  and  a  half  months'  pregnancy.  At  parts  the  swelling 
was  soft  and  doughy,  and  at  others  hard.  There  was  greater 
resistance  on  the  right  side  as  a  whole,  and  on  this  side  harder, 
irregular  masses  were  felt,  suggestive  of  limbs.  Foetal  heart 
sounds  were  audible  just  below  the  umbilicus  in  the  middle 


BY  DR  N.    T.    BREWIS.  199 

line.  Per  vaginam,  a  sense  of  doughiness  of  the  lower  uterine 
segment  was  felt.  For  a  week  she  continued  to  pass  clots,  and 
on  the  eighth  day  after  admission  she  had  a  profuse  haemorrhage, 
accompanied  by  severe  abdominal  pains,  having  the  character 
of  labour  pains.  The  patient  was  very  weak  and  exhausted. 
In  the  evening  of  that  day  it  was  decided  to  deliver  as  rapidly 
as  possible.  It  was  found  that  the  external  os  had  dilated 
very  slightly — only  sufficiently  to  allow  the  tip  of  a  finger  to  be 
introduced.     Chloroform  was  given. 

The  median  basilic  vein  was  exposed,  and  about  a  quart  of 
saline  given  intravenously.  The  vagina  was  then  well  douched 
out,  the  cervix  grasped  by  strong  volsellae,  and  pulled  down. 
An  incision  was  made  through  the  anterior  vaginal  wall 
transversely,  and  the  bladder  pushed  up.  A  sound  being 
passed  into  the  bladder,  an  incision  was  made  along  the  anterior 
surface  of  the  cervix  and  continued  beyond  the  internal  os. 
The  presenting  part  was  seen  as  a  bluish  sac.  The  membranes 
were  ruptured,  and  the  liquor  amnii  allowed  to  escape. 

On  introducing  the  fingers  the  placenta  was  felt  to  one 
side,  low  down,  and  the  head  of  the  child  was  presenting.  The 
child  was  delivered  by  forceps.  The  hand  was  then  introduced 
to  remove  the  placenta,  which  was  partially  adherent.  After 
expressing  the  placenta  the  interior  of  the  uterus  was  douched 
with  hot  sterile  water.  The  incisions  in  the  uterus  and  vagina 
were  closed  by  catgut  sutures.     She  made  a  good  recovery. 

This  case  was  one  of  premature  detachment  of  a  portion  of 
a  low-placed  placenta.  Possibly  at  an  earlier  stage  rupture  of 
the  membranes  or  slow  dilatation  followed  by  delivery  might 
have  been  successful,  but  at  the  time  that  I  operated  the 
patient  was  in  a  highly  critical  state,  and  I  felt  that  it  was 
best  for  the  patient  to  deliver  as  speedily  as  possible.  I  con- 
sidered her  condition  so  dangerous  that  I  transfused  before  the 
operation,  a  plan  which  I  always  practise  in  patients  exhausted 
from  loss  of  blood. 


200  SIX   CASES   OF   VAGINAL   CESAREAN   SECTION, 

The  indications  for  vaginal  section  submitted  by  Diihrssen 
eleven  years  ago,  were  for  conditions  dangerous  to  the  life  of 
the  mother  or  child,  or  both;  abnormalities  of  the  cervix  and 
lower  uterine  segment,  which  make  impossible  or  difficult  a 
dilatation  of  the  cervix  by  the  uterine  contractions ;  and  for 
dangerous  conditions  of  the  mother  which  may  be  removed 
by  prompt  emptying  of  the  uterus,  e.g.,  affections  of  the 
kidneys,  heart,  lungs. 

Whenever  the  element  of  time  is  important,  vaginal 
Cesarean  section  is  a  great  addition  to  our  resources.  An 
operation  which  enables  the  hand  to  pass  with  safety  into  the 
interior  of  the  pregnant  uterus  in  a  couple  of  minutes'  time  is 
one  which  might  have  its  indications  extended  to  cases  of  a  less 
serious  nature,  where  the  mother's  life  is  not  in  peril,  but 
where  the  operation  can  accomplish  the  desired  end  more  easily 
and  more  conveniently  than  any  other.  Anyone  who  has  had 
experience  of  this  operation  cannot  do  otherwise  than  commend 
it.  An  aseptic  field,  a  clean-cut  wound,  an  easy  and  rapid 
technique,  the  parts  restored  at  the  end  of  the  operation  to 
their  original  condition  by  a  few  catgut  stitches,  go  to  make 
an  operation  which  must  appeal  strongly  to  anyone  witli 
surgical  instincts. 

The  last  case  in  which  I  followed  Diihrssen's  method  was 
one  in  which  the  patient's  life  was  not  in  danger.  Her  uterus 
might  have  been  safely  emptied  by  other  means,  but  I  pre- 
ferred vaginal  Cesarean  section,  because  it  was  as  safe  as  any 
other,  and  was  more  easily  performed. 

Case  VI. — The  patient  was  two  and  a  half  months 
pregnant,  and  haemorrhage  had  gone  on  continuously  for  five 
weeks. 

All  the  mothers  recovered. 

A  living  seven  and  a  half  months'  child  was  delivered  in 


BY   DR   N.    T.    BREWIS.  201 

the  eclamptic  case,  and  a  full-time  child  in  the  case  of  stenosis 
of  the  cervix. 


Br  Lamond  Laekie  said  he  had  no  personal  experience  of 
the  operation,  but  that  during  the  last  quarter  at  the  Maternity 
Hospital  he  had  had  a  case  in  which  he  had  thought  of  doing 
vaginal  Cesarean  section.  The  case  was  one  of  eclampsia,  the 
patient  was  comatose,  and  the  prognosis  was  very  bad.  He 
had  attempted  to  dilate  the  os  with  Hegar's  bougies,  and  with 
Bossi's  dilator,  but  had  failed  absolutely.  The  cervix  was  so 
rigid  that  he  felt  it  would  be  wrong  to  persist  in  the  attempt, 
and  he  desisted,  with  the  view  of  performing  vaginal  Csesarean 
section  later.  Fortunately  the  patient  began  to  improve,  and 
by  the  following  day  no  further  interference  was  necessary.  In 
three  days  there  was  practically  no  sign  of  eclampsia,  the  fits 
had  ceased,  the  albumen  disappeared,  and  five  days  after  the 
attempted  dilatation 'of  the  cervix,  the  patient  aborted;  the 
fact  being  that  during  the  eclampsia  the  foetus  died.  Dr 
Brewis's  paper  was  most  interesting.  There  seemed  to  be  so 
many  possible  conditions  for  which  the  operation  might  be 
done.  He  had  noticed  that  Dr  Brewis  held  that  the  operation 
was  even  indicated  where  the  os  might  possibly  be  dilated, 
and  the  foetus  delivered  in  that  way.  He  supposed  the  opera- 
tion was  more  speedy  than  dilation  of  the  os,  when  from 
twenty  to  thirty  minutes  were  required,  so  that  there  was  a 
distinct  gain  in  that  way. 

Br  Haig  Ferguson  thanked  Dr  Brewis  for  his  paper.  He 
had  had  only  one  experience  of  vaginal  Caesarean  section,  but 
had  found  the  operation  extremely  satisfactory — so  much  so, 
that  if  again  in  similar  conditions,  he  would  prefer  it  to  Bossi's 
dilator,  which  he  considered  to  be  extremely  dangerous,  and 
very  seldom  satisfactory.     The  patient  was  a  primpara  with 


202  SIX  CASES   OF  VAGINAL  CESAREAN  SECTION, 

eclampsia.  She  was  about  seven  and  a  half  months,  had  had 
twelve  seizures,  and  was  comatose ;  the  cervix  was  very  rigid, 
no  sign  of  dilatation,  and  the  foetus  alive.  He  determined  to 
do  vaginal  Caesarean  section,  and  followed  the  ordinary  routine 
as  performed  by  Diihrssen,  and  got  the  uterus  dilated  in  a 
few  minutes,  and  delivered  the  child  (which  presented  by  the 
breech)  without  any  difficulty  at  all.  He  sewed  up  the  lower 
segment  and  restored  the  parts  to  their  former  condition. 
Unfortunately  the  patient  did  not  survive.  She  recovered 
consciousness,  but  again  had  a  succession  of  eclamptic  fits, 
and  in  spite  of  all  treatment  died  the  following  evening.  But 
he  was  so  impressed  with  the  ease  with  which  the  operation 
could  be  done,  that  in  a  case  of  eclampsia  he  should  certainly 
prefer  the  operation  to  the  use  of  Bossi's  dilator.  The  only 
thing  he  should  wish  to  criticise  was  in  doing  it  in  a  woman 
who  was  only  two  and  a  half  months  pregnant.  The  simplicity 
of  Diihrssen's  operation  was  when  the  woman  was  near  full 
time,  and  the  lower  uterine  segment  more  fully  developed. 
He  could  not  see  the  reason  why,  in  inducing  an  abortion  one 
should  have  recourse  to  vaginal  Caesarean  section,  for,  un- 
doubtedly, there  were  certain  risks;  the  incision  might  go  so 
far  up  as  to  open  the  peritoneal  cavity.  He  should  prefer  to 
induce  abortion  by  dilators  rather  than  risk  the  opening  of  the 
peritoneal  cavity.  The  only  other  point  was  in  regard  to  the 
indication  in  heart  cases.  He  thought  the  best  treatment 
was  medicinal,  and  to  avoid  bringing  on  labour.  He  had  found 
general  treatment  have,  as  a  rule,  satisfactory  results.  Cer- 
tainly in  cases  of  eclampsia,  and  possibly  in  placenta  praevia, 
where  one  knew  the  lower  uterine  segment  and  the  cervix  were 
extremely  friable,  a  clean  cut  such  as  Diihrssen  recommended 
— one  that  appealed  to  one's  surgical  principles,  and  one  that 
would  terminate  pregnancy  in  a  much  more  rapid  and  safe 
manner  without  setting  up  laceration,  was  much  better.  They 
were  much  indebted  to  Dr  Brewis  for  having  stepped  into  the 


BY   DR   N.    T.    BREWIS.  203 

breach  and  given  them  such  an  interesting  paper.  He  thought 
that  in  the  operation  one  needed  to  have  plenty  of  skilled 
assistants,  as  it  would  be  extremely  difficult  to  do  it  if  inade- 
quately assisted. 

The  President  agreed  with  the  Fellows  who  had  spoken,  in 

thinking  the  subject  a  very   interesting  one.     He   was   very 

glad  Dr   Brewis  had  come   forward   again  with  an   obstetric 

paper,  or  one  that  was  perhaps  just  on  the  border-line  between 

obstetrics   and   gynaecology,   for   vaginal    sections   were   more 

especially  gynaecological.      The  indications  for   the   operation 

had  struck  him  as  being  extremely  interesting  from  their  variety 

— vomiting,  eclampsia,  stenosis  of  os,  heart  disease,  placenta 

praevia.     It  seemed  to  him  that  one  might  generalise  a  little 

more,  and  say  that  cases  in  which  the  os  was  not  taken  up  were 

specially  suitable  ones.     In  eclampsia,  where  the  os  was  taken 

up   the    case    might    be    amenable    to    other    measures,    but 

where  it  was  not  taken  up  there  was  great  risk  in  using  Bossi's 

dilator,  which  gave  the  risk  of  severe  laceration.     Formerly, 

the    only    operation    consisted    in    numerous    incisions    into 

the   cervix,   which   had   seemed  to  him  to  tempt  danger  and 

possible    disaster.      But    this   localised   clean   cut    did    seem 

to    meet    the    indication    where    the    os   was   not   taken  up, 

and    thus   in   cases   which   were   not    far    on    in   pregnancy. 

He    thought   the   reason   why    the   operation    was   chosen   in 

the  heart  case  was  that  there  was  a  condition  of  a  systole, 

and  that  the  case  was  not  like  many  cases  in  which  it  would 

not  matter  if  one  waited  for  a  while.     In  such  a  case  as  that 

cited,  he  considered  one  would  be  quite  justified  in  doing  the 

operation.     He  supposed    that   a   knife,   scissors,  and   catgut 

sutures  were  about  all  that  was  needed  for  the  operation.     He 

was  sure  he  expressed  the  feelings  of  the  Society  in  thanking 

Dr  Brewis  for  coming  forward  at  such  short  notice,  and  for 

giving  them  such  an  interesting  paper. 

Dr  Brewis  thanked  the  President  and  Fellows  for  the  very 


204        CONGENITAL  GOITKE  FOLLOWING   ADMINISTRATION   OF 

kind  way  in  which  they  had  received  his  paper,  though  it  was 
somewhat  obstetrical.  He  considered  the  cases  related  in  the 
paper  belonged  to  the  gynaecology  of  obstetrics.  He  could  not 
agree  with  those  who  thought  the  operation  only  suitable  for 
hospital.  The  first  case  narrated  was  performed  in  a  private 
house,  without  any  special  preparation,  and  with  a  few 
borrowed  instruments.  A  pair  of  scissors,  two  volsellse  or 
forceps,  a  small  curved  needle,  and  catgut  are  all  the  instru- 
ments that  are  specially  needed.  No  doubt  this,  like  all  other 
operations,  is  best  performed  in  hospital,  but  when  the  patient 
is  not  fit  to  be  removed,  there  is  no  reason  why  she  should  not 
have  the  benefit  of  the  operation  in  her  own  house.  With 
regard  to  the  opinion  offered  by  Dr  Haig  Ferguson  on  the 
justifiableness  of  operation  in  the  case  of  heart  disease,  Dr 
Brewis  thought  that  if  Dr  Ferguson  had  seen  the  case  he 
would  not  have*  hesitated  to  recommend  the  operation.  Dr 
Brewis  considered  that  the  operation  saved  the  patient  from  a 
perilous  position,  and  probably  saved  her  life.  Dr  Brewis  did 
not  consider  there  was  more  danger  in  this  than  in  any  other 
obstetric  operation,  and  on  that  account  he  would  prefer  it  in 
some  cases  of  abortion.  In  none  of  the  cases  had  he  found  it 
necessary  to  make  the  posterior  incision  through  the  cervix. 


V.  A  CASE  OF  REPEATED  ABORTION  DUE  TO  SYPHILIS ; 
TREATMENT  BY  POTASSIUM  IODIDE;  BIRTH  OF 
CHILD  WITH  CONGENITAL  GOITRE. 

By  B.  P.  Watson,  M.D.,  F.R.C.S.E.,  University  Gynaecological  Tutor, 
Royal  Infirmary,  Edinburgh ;  Gynaecologist  to  the  Cowgate  Dispen- 
sary, Edinburgh. 

Four  years  ago  papers  were  read  before  this  Society  by  Dr 
Angus  Macdonald  and  Dr  Fothergill,  giving  accounts  of  two 
cases  in  which  after  the  administration  of  potassium  chlorate  to 
the  mothers  during  pregnancy,  children  were  born  with  enlarged 


POTASSIUM   IODIDE,   BY  DR  B.    P.    WATSON.  205 

thyroid  glands.  About  the  same  time  a  paper  appeared  in  the 
British  Medical  Journal,  by  Hewetson,  in  which  he  described 
the  appearances  of  the  much  enlarged  thyroid  gland  of  a  child 
born  after  the  administration  of  potassium  chlorate  and  potassium 
iodide  to  the  mother.  Cases  following  the  administration  of 
potassium  chlorate  had  previously  been  recorded  by  Sir  J.  Y. 
Simpson  in  1855,  and  Dr  (now  Sir)  A.  E.  Simpson  in  1866. 

Apart  from  these  I  know  of  no  other  cases  in  which  hyper- 
trophy of  the  foetal  thyroid,  has  followed,  or  been  coincident 
with  the  administration  of  such  drugs  to  the  mother  during 
pregnancy,  and  this  is  my  reason  for  bringing  the  present  case 
before  the  Society. 

The  case  has  a  further  interest,  in  that  it  shows  in  a  marked 
manner  the  action  of  potassium  iodide  in  preventing  intra- 
uterine death  of  the  child  in  a  case  of  maternal  syphilis. 

The  history  is  as  follows : — 

Mrs  C,  age  27,  came  to  me  at  the  Cowgate  Dispensary  four 
years  ago.  Five  years  previously  she  had  been  married,  and 
when  pregnant  with  her  first  child  had  been  infected  with 
syphilis.  The  local  manifestations  of  the  disease  were  very 
pronounced,  and  a  considerable  amount  of  ulceration  seems  to 
have  occurred.  She  carried  the  child  to  full  time,  but  it  died 
during  delivery  by  forceps.  As  far  as  she  knew,  it  presented 
no  sign  of  disease.  Her  attendant  at  the  confinement  informed 
her  of  the  nature  of  her  disease,  and  after  the  birth  of  the  child 
she  had  sore  throat,  her  hair  fell  out,  and  a  rash  appeared  on 
the  body. 

Following  in  rapid  succession  after  the  birth  of  her  first 
child  she  had  a  series  of  five  miscarriages:  the  first  at  the 
seventh  month,  second  at  third  month,  third  at  seventh  month, 
fourth  at  three  and  a  half  months,  and  fifth  at  seventh  month. 
The  seven-months'  foetuses  were  all  born  in  a  macerated  con- 
dition, and  had  evidently  been  dead  in  utero  for  periods  varying 
from  a  week  to  a  fortnight.     The  patient  mentioned  that  after 


206      CONGENITAL   GOITRE   FOLLOWING  ADMINISTRATION   OF 

each  miscarriage  she  was  troubled  with  a  sore  throat,  and  that 
her  hair  fell  out  much  more  that  usual.  I  had  not  previously 
heard  patients  with  syphilis  complain  of  this.  It  looked  as  if 
there  were  a  fresh  dose  of  the  poison  liberated  as  each  ovum 
was  cast  off.  I  may  say  that  the  husband  who  infected  her  had 
never  been  treated. 

When  I  first  saw  her  she  was  two  months  advanced  in  her 
seventh  pregnancy  and  was  extremely  anxious  to  have  a  living 
child.  She  was  given  a  mixture  containing  potassium  iodide, 
aromatic  spirit  of  ammonia,  and  infusion  of  gentian,  and  in- 
structed to  take  a  dose  containing  10  gr.  of  the  iodide  three 
times  daily.  She  carried  out  the  instructions  faithfully,  and 
took  30  gr.  of  iodide  every  day  right  up  to  the  onset  of  labour. 
The  course  of  the  pregnancy  was  normal  in  every  respect,  and 
her  child  was  born  at  full  time,  alive,  well  nourished,  and 
apparently  healthy.  The  placenta  was  large  and  flabby,  with  a 
few  infarcts,  but  otherwise  normal  in  appearance.  In  a  week 
the  child  developed  signs  of  syphilis,  with  a  character- 
istic rash  over  the  buttocks,  and  snuffles,  and  a  week  later  it 
died.  I  had  not  an  opportunity  of  making  a  post-mortem 
examination. 

Four  months  later  the  patient  again  became  pregnant,  and 
from  the  second  month  onward  she  took  30  gr.  of  potassium 
iodide  per  diem.  The  pregnancy  was  going  on  normally  up  to 
the  end  of  July  1905,  when  she  had  completed  her  seventh 
month:  foetal  movements  were  then  strong  and  the  heart 
audible.  The  Dispensary  being  closed  in  August,  she  was  given 
what  was  thought  to  be  sufficient  medicine  to  last  her  over  the 
month.  It  had,  however,  been  finished  about  ten  days  before 
the  end  of  the  month,  and  during  that  time  she  had  taken  none. 
She  came  to  see  me  on  3rd  September,  and  said  she  had  felt  no 
movements  for  the  past  three  or  four  days,  and  that  she  feared 
the  child  was  dead.  Ten  days  later  she  gave  birth  to  a 
macerated  foetus  which  had  evidently  been  dead  for  about   a 


POTASSIUM   IODIDE,   BY  DR   B.    P.    WATSON.  207 

fortnight.  The  placenta  was  large,  and  contained  many  large 
infarcts. 

In  February  1906  she  again  became  pregnant,  and  the  same 
line  of  treatment  was  followed  throughout,  viz.,  the  adminstra- 
tion  of  30  gr.  of  potassium  iodide  a  day  from  the  second  month 
up  to  the  time  of  labour.  She  carried  her  child  to  full  time, 
had  an  easy  labour,  and  made  a  satisfactory  recovery. 

The  child,  a  male,  at  birth  weighed  6J  lbs.,  and  appeared  in 
every  way  healthy,  except  that  it  had  a  large  swelling  in  the 
neck  in  the  region  of  the  thyroid  gland.  The  two  lobes  were 
equally  enlarged,  extending  up  the  neck  on  each  side  of  the 
trachea,  and  there  was  also  considerable  thickening  of  the 
isthmus.  The  swelling  did  not  extend  below  the  level  of  the 
manubrium  sterni.  There  was  very  considerable  embarrassment 
of  respiration,  inspiration  being  accompanied  by  loud  stridor. 
The  breathing  was  always  more  laboured  when  the  child  was 
laid  on  its  back,  or  if  the  head  became  extended ;  it  would  then 
become  extremely  cyanosed.  It  was  unable  to  suckle,  and  had 
to  be  fed  by  spoon.  For  the  first  fortnight  after  birth  there 
was  no  perceptible  change  in  the  goitre,  but  after  that  it  beo-an 
to  undergo  a  slow  but  progressive  decrease  in  size  with  a 
corresponding  diminution  in  the  respiratory  difficulty.  From 
the  fourth  week  the  child  began  to  show 'signs  of  congenital 
syphilis.  For  this,  as  well  as  for  the  obstinate  constipation 
from  which  it  suffered,  it  was  treated  with  grey  powder.  When 
three  months  old  there  was  well-marked  cranio-tabes  present. 
In  spite  of  its  obvious  syphilitic  condition  the  child  throve 
fairly  well  up  to  the  age  of  three  and  a  half  months,  when  it 
developed  epidemic  cerebro-spinal  meningitis.  It  was  sent  to 
the  Eoyal  Hospital  for  Sick  Children,  under  Dr  John  Thomson's 
care,  where  it  died  after  being  ill  for  ten  days.  Dr  Stuart 
M'Donald  performed  the  post-mortem,  and  to  him  I  am  in- 
debted for  the  following  notes : — 

Thorax. — There  is  a  large  goitre  present,  which   measures 


208      CONGENITAL   GOITRE   FOLLOWING   ADMINISTRATION   OF 

about  2\  inches  across  from  side  to  side.  It  is  compressing  the 
trachea  laterally,  is  firm  and  elastic  in  feeling,  and  on  section 
looks  like  normal  thyroid  tissue. 

Heart. — Some  dilatation  of  right  side;  no  endocarditis; 
myocardium  soft  and  flabby. 

Lungs. — Both  congested  and  cedematous,  with  patches  of 
lobular  collapse  and  emphysema;  there  is  extensive  broncho- 
pneumonic  consolidation  of  left  lower  lobe  and  of  upper  lobe  on 
right  side.  The  larger  bronchi  are  congested  ;  bronchial  glands 
not  enlarged. 

Abdomen. — Spleen  shows  acute  congestion,  pale ;  Malpighian 
bodies  present. 

Ziver. — Cloudy  and  fatty.     Marked  inter-cellular  cirrhosis. 

Bones. — Marrow  of  ribs  red  and  lymphoid.  Marked  cranio- 
tabes  present. 

Brain  and  Cord. — Acute  leptomeningitis,  basal  and  vertical. 
Convolutions  flattened.  Great  dilatation  of  superficial  vessels. 
Exudate  most  marked  in  sulci ;  yellow  in  appearance,  very  like 
a  pneumococcal  case  in  appearance. 

Cord. — External  pachymeningitis  over  lower  part  of  cord; 
thick  fibrinous-looking  exudate  present;  there  is  diffuse  lepto- 
meningitis of  cord,  exudate  resembling  that  over  brain. 

The  two  chief  points  of  interest  in  the  case  are : — 

1st.  The  action  of  potassium  iodide  in  preventing  intra- 
uterine death ;  and 

2nd.  The  enlargement  of  the  thyroid  gland  of  the  last  child 
after  the  administration  of  potassium  iodide  to  the  mother 
during  pregnancy. 

(1)  That  the  potassium  iodide  did  have  an  influence  in 
enabling  the  patient  to  carry  her  children  to  full  time,  and  that 
this  was  not  merely  due  to  the  gradual  elimination  of  the 
syphilitic  poison  from  her  system  with  the  lapse  of  time,  is,  I 
think,  clearly  shown  by  the  history  of  the  second  pregnancy, 
during  which  she  had  the  drug  administered.     In  the  first  and 


POTASSIUM   IODIDE,   BY  DR   B.    P.   WATSON.  209 

third  pregnancies  under  treatment  she  took  30  gr.  of  iodide 
daily,  right  up  to  the  onset  of  labour,  and  in  both  cases  full- 
time,  living  children  were  born.  In  the  second  pregnancy  the 
stoppage  of  the  drug  for  a  fortnight  at  the  eighth  month  was 
followed  by  the  death  of  the  child,  and  I  think  we  are  justified 
in  concluding  that  the  one  was  a  direct  result  of  the  other. 

It  is  to  be  noted,  however,  that  while  potassium  iodide 
seemed  to  enable  the  patient  to  have  living  children,  it  did  not 
prevent  the  subsequent  development  of  well-marked  signs  of 
congenital  syphilis  in  these  children.  For  this  reason  I  shall, 
in  future,  in  cases  of  a  similar  kind,  combine  mercury  with 
potassium  iodide,  as  is  usually  recommended. 

I  gave  potassium  iodide  alone  in  this  case,  as  in  a  previous 
case  of  repeated  miscarriage  with  no  syphilitic  history  it  had 
been  successful,  the  patient  having  a  full-time,  living  child, 
and  I  thought  that  it  would  be  doubly  efficacious  in  the  present 
one.  Lomer  gives  a  record  of  twenty  cases  of  habitual  abortion 
due  to  syphilis,  albuminuria,  and  endometritis,  successfully 
treated  by  potassium  iodide  and  iron.  He  supposes  that  the 
iodide  acts  by  preventing  placental  haemorrhages,  which  so 
often  precede  the  death  of  the  foetus.  Other  observers  have  had 
good  results  in  similar  cases  with  potassium  iodide. 

Potassium  chlorate  is  the  drug  which,  on  the  original  recom- 
mendation of  Sir  J.  Y.  Simpson,  is  usually  employed  in  non- 
syphilitic  cases.  Its  mode  of  action  is  still  in  dispute ;  the 
hypothesis  that  it  parts  with  its  oxygen  to  the  foetal  blood 
having  been  disproved.  Fothergill  believes  that  it  acts  by 
preventing  excessive  clotting  in  the  intervillous  spaces  of  the 
placenta. 

The  apparently  equally  good  results  which  follow  the  use  of 
potassium  iodide,  even  in  definitely  non-syphilitic  cases,  seem  to 
suggest  that  it  is  the  potassium  which  is  the  essential  element, 
and  that  the  particular  salt  employed  does  not  so  much  matter. 
This  possibility  was  mentioned  by  Dr  Ballantyne  in  the  discus- 

O 


210      CONGENITAL  GOITRE   FOLLOWING  ADMINISTRATION   OF 

sion  on  Dr  Fothergill's  paper,  and  he  was  led  to  mention  it 
from  a  knowledge  of  the  fact  that  large  quantities  of  potassium, 
together  with  lime  and  iron,  pass  to  the  foetus  in  the  last  three 
months  of  pregnancy.  Both  potassium  iodide  and  potassium 
chlorate  are  readily  diffusible  salts,  and  quickly  pass  to  the 
foetus  after  introduction  into  the  circulation  of  the  mother.  In 
the  present  case  I  had  the  placenta  examined  for  the  presence 
of  the  salt,  but  none  was  found,  owing  probably  to  the  compara- 
tively small  dose  the  mother  was  taking  and  the  rapidity  of  its 
excretion. 

It  would  serve  no  useful  purpose  to  mention  the  various 
views  that  are  held  as  to  the  mode  of  action  of  these  salts  in 
preventing  intra-uterine  death,  and  I  only  refer  to  the  possi- 
bility of  the  potassium  being  the  essential  element  in  order  to 
suggest  that  in  similar  cases  it  might  be  of  interest  to  try  the 
effect  of  some  of  its  other  salts,  and  note  whether  they  were 
equally  efficacious. 

(2)  The  occurrence  of  thyroid  enlargement  in  the-  last  child. 
Congenital  goitre  is,  under  any  circumstances,  of  comparatively 
rare  occurrence,  so  that  to  find  six  cases  following  the  adminis- 
tration of  potassium  salts  to  the  mother  during  pregnancy,  for 
the  prevention  of  foetal  death,  seems  more  than  coincidence. 
At  the  same  time  it  is  difficult  to  arrive  at  any  adequate 
explanation  of  them. 

In  the  cases  of  Sir  J.  Y.  Simpson,  Sir  A.  E.  Simpson, 
Macdonald  and  Fothergill,  potassium  chlorate  was  the  drug 
used,  in  Hewetson's  case  potassium  chlorate  and  potassium 
iodide,  and  in  my  own  potassium  iodide  alone. 

In  none  of  these  six  cases  was  there  any  history  of  goitre  in 
the  families,  whereas  in  a  large  proportion  of  the  other  cases  of 
congenital  goitre  reported  one  or  both  of  the  parents  have  been 
goitrous.  Four  of  the  six  cases  died  shortly  after  birth  as  the 
result  of  tracheal  compression;  and  in  the  two  that  survived — 
Sir  A.  E.  Simpson's  and  my  own — the  thyroid   underwent  a 


Hypertrophy  of  Foetal  Thyroid. 


[To  f<u,t  page  211 


POTASSIUM   IODIDE,   BY  DK   B.   P.    WATSON.  211 

progressive  decrease  in  size  from  birth  onwards — a  phenomenon 
noted  in  most  cases  of  true  congenital  goitre. 

In  Fothergill's  and  Hewetson's  cases,  in  which  the  child 
died  shortly  after  birth,  detailed  reports  are  given  of  the  histo- 
logical appearances  of  the  glands.  In  the  former  there  was  a 
large  quantity  of  glandular  tissue  of  an  adenomatous  type, 
with  many  large  blood-vessels  in  the  connective  tissue  septa. 
In  the  latter  the  glandular  tissue  was  not  so  abundant,  being 
represented  by  a  loose  mesh-work  of  connective  tissue,  lined  by 
round  and  flat  cells  in  one  or  more  layers,  but  the  blood-vessels 
were  very  large  and  numerous,  and  Hewetson  classifies  it  under 
the  vascular  or  congestive  type  of  goitre,  which  is  the  com- 
monest type  in  congenital  cases. 

In  neither  case  was  there  any  colloid  present  in  the  acini. 
Although  there  is  no  histological  report  on  Macdonald's  case, 
the  fact  that  there  were  variations  in  size  within  short  intervals, 
apparently  clue  to  intermittent  congestion,  probably  indicates 
that  it  also  belonged  to  the  congestive  variety,  and  from  the 
description  of  Sir  J.  Y.  Simpson's  case  it  may  also  have  been  of 
this  type. 

In  the  present  case  the  enlargement  of  the  thyroid  is  due 
to  a  general  parenchymatous  overgrowth  of  the  gland.  There 
is  a  large  quantity  of  colloid  present,  the  vesicles  being  widely 
distended  with  it,  and  a  very  little  inter- vesicular  substance  is 
left.  The  cells  lining  the  vesicles  are  low  and  compressed 
looking.  In  fact,  the  appearances  are  exactly  those  met  with 
in  parenchymatous  goitres  occurring  in  the  adult  (see  Plate). 

It  must  be  remembered  that  the  present  differs  from 
Fothergill's  and  Hewetson's  cases  in  that  the  child  was  nearly 
four  months  old  at  its  death,  whereas  theirs  were  only  a  few 
hours  old.  In  Hewetson's  case,  moreover,  the  child  was  a 
seven  months  one.  Then,  again,  the  present  child  died  after 
an  acute  febrile  disease  lasting  for  twelve  days.  What  the 
exact  condition  of  the  gland  was  at  birth  can  only  be  a  matter 


212      CONGENITAL   GOITEE  FOLLOWING  ADMINISTRATION   OF 

of  speculation,  but  it  can  hardly  have  belonged  to  the  vascular 
variety  of  goitre  described  by  Hewetson,  as  the  vessels  in  it 
are  not  at  all  numerous,  and  those  present  are  not  large  or 
dilated.  It  is  more  likely  that  from  the  first  it  had  been  of 
the  parenchymatous  variety. 

Such  are  the  facts  regarding  these  cases,  but  when  we  try 
to  arrive  at  an  explanation  of  them  we  are  met  with  many 
difficulties. 

In  the  first  place,  it  is  not  possible  to  say  whether  the 
enlarged  thyroid  glands  of  these  children  were  functioning  or 
not.  The  absence  of  colloid  in  Fothergill's  and  Hewetson's 
cases  would  lead  us  to  suppose  that  the  glands  were  function- 
less,  for  it  is  the  colloid  which  contains  the  active  principle. 
But  in  my  own  case  the  presence  of  colloid  does  not  necessarily 
point  to  functional  activity,  for  colloid  may  be  present  and  yet 
contain  no  thyroidin,  which  is  the  active  principle,  and  without 
which  the  colloid  is  said  to  be  inert.  J.  W.  Simpson,  in  a 
paper  on  "  The  Thyroid  Gland  in  Eelation  to  Marasmus," 
recently  published,  points  out  that  though  colloid  may  be 
present  in  the  thyroid  glands  of  new-born  children,  and  even 
premature  infants,  it  may,  on  chemical  examination,  be  found 
to  contain  no  active  principle ;  and  he  believes  that  new-born 
and  young  infants  have  little  or  no  efficient  thyroid  secretion. 
In  none  of  these  six  cases,  unfortunately,  has  any  chemical 
examination  of  the  gland  been  made,  so  that  we  cannot  say 
whether  the  glands  were  functionally  active  or  not.  That  is 
the  first  difficulty. 

Secondly,  granting — which  I  think  we  must — that  the 
hypertrophy  of  the  foetal  thyroid  following  drug  treatment  of 
the  mother  for  repeated  abortion  in  these  cases  was  not  a  mere 
coincidence,  two  explanations  are  possible :  first,  that  the  hyper- 
trophy is  due  to  the  action  of  the  drug  given ;  and  second,  that  it 
is  due  to  the  condition  of  the  mother's  blood,  which  caused  the 
abortions  and  necessitated  the  administration  of  the  drugs. 


POTASSIUM  IODIDE,   BY  DR   B.    P.    WATSON.  213 

If  Hewetson's  and  my  own  had  been  the  only  cases  of  the 
kind  recorded,  we  should  have  been  strongly  tempted  to  have 
ascribed  the  thyroid  hypertrophy  to  the  administration  of 
potassium  iodide,  which  is  known  to  have  some  action  on  the 
thyroid  secretion  by  virtue  of  the  iodine  which  it  contains. 
But,  in  the  other  four  cases,  only  potassium  chlorate  was  given, 
and  no  iodide.  This  serves  to  show  how  careful  we  must  be  in 
jumping  to  conclusions. 

On  the  whole,  I  am  inclined  to  think  that  the  hypertrophy 
is  just  as  likely  to  be  due  to  the  condition  of  the  mother's 
blood  as  to  the  action  of  the  drug  given.  Simpson  points  out 
that  adults  suffering  from  tuberculosis,  alcoholism,  and  syphilis 
almost  invariably  have  sclerosis  of  the  thyroid  gland,  and  that 
there  is  constantly  a  sclerosis  in  the  gland  of  children  of  tuber- 
culous mothers.  As  he  puts  it,  "unhealthy  parentage  may 
produce  degenerative  changes  in  the  thyroid  of  the  offspring/' 

It  is  possible  that  in  this  is  to  be  found  an  explanation  of 
such  cases  as  the  present  one  and  those  previously  recorded. 

But  in  the  present  state  of  our  knowledge  of  thyroid 
physiology,  not  to  mention  the  diversity  of  opinion  held  re- 
garding the  mode  of  action  of  such  drugs  as  potassium  iodide 
and  potassium  chlorate,  we  cannot  arrive  at  any  definite  con- 
clusion as  to  their  true  etiology,  and  must  meanwhile  be  con- 
tent with  placing  them  on  record. 

Eeferences. 

Ballantyne. — "  Antenatal  Pathology."    Edinburgh,  1902. 
Fothergill.— Edin.  Obst.  Trans.,  1903-1904,  p.  41. 
Hewetson. — Brit.  Med.  Journ.,  1903,  vol.  i.,  p.  657. 
Macdonald  (Angus). — Edin.  Obst.  Trans.,  1902-1903. 
Lomer. — Zeit.f.  Geburt  u.  Gyn.,  lxvi.,  Hf.  2. 
Simpson  (Sir  A.  K).~Glasgoiv  Med.  Journ.,  1866,  p.  181. 
Simpson  (J.  W.).~-~Scot.  Med.  and  Surg.  Journ.,  1906. 
Simpson  (Sir  J.  Y.).— Monthly  Journ.  of  Med.  Scien.,  1855,  p.  350. 


214      CONGENITAL  GOITRE  FOLLOWING  ADMINISTRATION  OF 

Dr  Ritchie  thought  they  might  congratulate  themselves  on 
having  had  a  most  interesting  paper,  giving  one  more  case  in 
addition  to  many  already  recorded,  of  the  advantage  of  potassium 
iodide  in  cases  where  death  of  foetus  occurred  in  utero. 
Dr  Watson  suggested  they  might  try  whether  other  potassium 
salts  might  not  be  equally  useful.  He  questioned  whether 
one  was  quite  justified  in  making  such  experiments,  when  one 
knew  the  great  advantage  of  iodide  of  potassium  as  an  almost 
unfailing  certainty.  He  had  listened  with  great  interest  to 
Dr  "Watson's  discussion  as  to  the  relation  of  the  enlarged  thyroid 
to  the  case,  and  he  quite  agreed  that  they  could  not  come  to 
any  definite  conclusion  as  to  the  precise  relation.  It  seemed 
to  be  quite  clear  that  debility,  alcoholism,  unhealthy  conditions, 
were  liable,  in  certain  persons,  to  be  followed  by  some  peculiarity 
of  the  thyroid  gland. 

Dr  Oliphant  Nicholson  thought  Dr  Watson  had  contributed 
a  very  valuable  paper  to  the  Society,  and  yet  it  seemed  that,  if 
possible,  he  had  made  an  obscure  subject  still  more  obscure. 
The  thyroid  gland  seemed  to  have  a  special  affinity  for  iodine, 
which  was  evidenced  by  the  fact  that  there  was  a  large  quantity 
of  iodine  in  the  thyroids  of  animals  which  were  getting 
potassium  iodide  given  to  them  along  with  their  ordinary  food. 
Iodine  was  certainly  an  essential  element  in  the  internal 
secretion  of  the  gland ;  therefore  the  gland  had  to  rely,  in  the 
ordinary  way,  upon  the  traces  of  iodine  contained  in  the  food. 
Thus  when  one  gave  potassium  iodide  to  a  person  it  might  be 
assumed  that  the  thyroid  activity  of  that  person  was  increased ; 
the  gland  would  pick  the  additional  iodine  out  of  the  blood, 
and  elaborate  it  into  iodothyrin.  The  remarkable  therapeutic 
properties  of  iodide  of  potassium  in  so  many  widely  different 
pathological  conditions  were  difficult  to  explain,  unless  the 
drug  acted,  as  had  been  suggested  recently,  by  modifying  the 
thyroid  activity  in  some  way.  Thus  iodide  of  potassium  and 
thyroid    extract    were    to    a   certain    extent    interchangeable 


POTASSIUM  IODIDE,   BY  DR  B.    P.    WATSON.  215 

remedies  in  certain  diseases.  Iodide  of  potassium  was  often 
given  quite  empirically,  e.g.,  in  very  large  doses  to  arrest  the 
secretion  of  milk.  This  was  a  very  precise  way  of  arresting 
milk,  and  it  seemed  quite  probable  that  the  result  was  brought 
about  by  the  iodide  producing  some  alteration  in  the  thyroid 
activity.  When  the  thyroid  gland  became  enlarged  in  a 
young  person — a  parenchymatous  goitre —such  a  condition 
certainly  occurred  in  the  first  instance  as  the  result  of  a  call 
by  the  tissues  for  an  increased  supply  of  thyroid  secretion. 
He  thought  it  allowable  to  assume  that  in  the  fcetus 
the  same  explanation  held  good — that  for  some  reason  the 
foetal  thyroid  was  making  an  attempt  to  cope  with  increased 
work.  Whether  the  extra  secretion  was  called  for  to  help  the 
mother,  or  to  meet  some  increased  strain  on  its  own  metabolism, 
he  could  not  say.  The  etiology  of  simple  goitre  was  still  very 
obscure ;  when  occurring  in  certain  districts  in  endemic  form, 
it  was  due  to  the  presence  of  something  in  suspension  in  the 
drinking-water  of  the  district.  If  the  people  living  in  that 
district  drank  rain-water,  they  did  not  develop  goitres.  It  was 
not  yet  proved  whether  the  substance  in  the  water  was  organic 
or  inorganic,  but  recently  Major  M'Carrison  had  shown  that 
large  doses  of  thymol  caused  ordinary  simple  goitres  to  greatly 
diminish  in  size,  and  sometimes  to  disappear.  He  suggested 
that  the  condition  was  of  bacterial  origin.  When  that  point 
was  ascertained,  it  might  throw  further  light  on  the  occurrence 
of  goitre  in  the  foetus.  Dr  Chalmers  Watson  had  carried  out 
some  interesting  experiments  in  feeding  certain  animals  on  an 
exclusive  meat  diet,  which  might  throw  some  light  on  these 
cases  of  foetal  thyroid  hypertrophy.  Such  a  dietary  induced  a 
very  marked  hypertrophy  of  the  thyroid  gland.  If  the 
explanation  was  that  the  hypertrophy  of  the  gland  resulted 
because  such  a  diet  contained  no  calcium  salts,  it  was  a  matter 
of  considerable  interest.  The  enlargement  of  a  foetal  thyroid 
might  be  connected  in  some  way  with  a  diminished  amount  of 


216      CONGENITAL   GOITRE   FOLLOWING  ADMINISTRATION  OF 

calcium  passing  to  it  from  the  mother.  During  pregnancy  it 
was  known  that  the  quantity  of  lime  salts  in  the  mother's 
tissues  might  vary  very  greatly  from  time  to  time.  Dr  Blair 
Bell  had  shown  that  the  thyroid  activity  was  closely  related  to 
the  calcium  exchange  in  the  tissues.  At  present  there  were 
a  great  many  isolated  facts  about  the  thyroid  gland  in  relation 
to  pregnancy  and  lactation,  but  it  seemed  impossible  to  correlate 
them  and  bring  them  into  line — one  fact  seemed  to  be  abso- 
lutely contradictory  to  another.  Much  more  light  was  needed. 
He  had  always  used  potassium  iodide  throughout  the  course  of 
pregnancy  in  cases  where  death  of  the  foetus  had  occurred,  and, 
in  many  cases,  with  very  good  results.  Sometimes  under  this 
treatment  a  woman  went  to  full  term ;  at  all  events,  one  was 
generally  able  to  prolong  the  pregnancy  till  the  child  was  of 
viable  age.  He  had  never  seen  an  enlarged  fcetal  thyroid  in 
these  cases,  because  evidently  the  necessary  factors  for  its 
production  had  not  been  present.  Dr  Watson  had  added  an 
important  contribution  to  a  very  interesting  subject. 

Dr  Keppie  Paterson  had  listened  with  great  interest  to  the 
paper,  and  also  to  the  remarks  of  the  other  speakers.  Dr 
Nicholson's  statement  that  he  had  treated  several  cases  all 
through  pregnancy,  but  had  not  found  any  case  of  enlarged 
thyroid,  was  an  important  contribution  in  itself.  Eeferring  to 
his  own  experience,  he  had  given  up  the  use  of  iodide  of 
potassium.  In  practice  he  had  attended  many  women  with 
syphilitic  abortions.  They  could  be  placed  in  two  classes.  In 
some  there  were  definite  signs  of  an  attack  of  syphilis,  with 
rash,  falling  out  of  the  hair,  and  all  the  usual  signs — these 
cases  were  rare;  in  most  cases  there  was  simply  a  syphilitic 
dyscrasia,  the  patient  becoming  thinner  and  weaker,  with 
perhaps  falling  out  of  the  hair.  This  bad  state  of  general 
health  occurred  during  a  pregnancy  and  continued  after  the 
abortion  or  pregnancy  was  over.  He  had  at  first  treated 
these   cases   with   iodide    of    potassium,   and    perchloride    of 


POTASSIUM   IODIDE,   BY  DR   B.    P.   WATSON.  217 

mercury,  but  had  very  soon  given  up  the  use  of  the  iodide,  and 
for  many  years  had  only  given  the  perchloride  of  mercury,  and 
with  very  great  benefit.  Patients  almost  always  fattened 
upon  it,  and  one  was  then  almost  certain  that  they  would  carry 
to  full  time  and  bear  a  healthy  child.  How  iodide  of  potassium 
or  perchloride  of  mercury  acted  in  the  case  of  syphilis  was 
probably  due  to  some  effect  on  the  opsonins.  He  related  an 
instructive  case  whom  he  had  attended  in  a  few  pregnancies. 
She  had  two  still-born  children,  and  she  came  under  his  care 
during  her  third  pregnancy,  when  he  treated  her  with  iodide  of 
potassium  and  mercuric  perchloride.  This  child  was  also  still- 
born. He  advised  her  to  put  herself  under  treatment  when- 
ever she  again  passed  a  period ;  this  she  did,  and  the  treatment 
was  efficacious,  as  she  gave  birth  to  a  living  child  about  full 
time,  who  has  never  shown  any  signs  of  congenital  syphilis. 
At  her  next  pregnancy  she  did  not  begin  the  medicine  until 
about  the  fourth  month,  and  this  ended  in  a  still-born  child. 
Her  next  conception  was  treated  very  early,  at  the  fifth  or 
sixth  week,  with  perchloride  internally,  and  resulted  in  a 
healthy  child.  She  was  again  careless  at  her  next  pregnancy, 
delaying  the  commencement  of  the  drug,  and  it  again  ended  in 
a  still-birth.  In  most  cases  he  gave  -^  gr.  of  perchloride  of 
mercury  thrice  daily,  beginning  early  until  after  the  fourth 
month,  and  then  only  twice  daily.  In  many  cases  a  course  of 
mercury  during  one  pregnancy  was  enough,  and  subsequent 
pregnancies  ended  in  healthy  children.  In  other  cases  where 
there  was  a  bad  dose  of  parasyphilis,  and  where  probably  the 
husbands  had  a  bad  form  of  syphilis,  it  was  necessary  to  give 
treatment  during  each  pregnancy.  He  had  used  the  per- 
chloride in  preference  to  any  other  form  of  mercury,  as  he  had 
been  taught  in  Vienna  that  in  whatever  form  mercury  was 
administered,  even  as  inunction,  it  only  did  good  because  it 
was  converted  into  the  perchloride. 

Dr  Haig  Ferguson  said  that  the  woman  seemed  to   get   a 


218      CONGENITAL  GOITRE  FOLLOWING   ADMINISTRATION  OF 

fresh  infection  after  each  pregnancy.  Dr  Watson  had  mentioned 
that  the  husband  had  never  been  treated  for  syphilis.  He 
had  seen  women  treated  for  years  for  syphilis  with  iodide  of 
potassium  and  mercury,  but  he  had  never  seen  a  case  of  f  oetal 
goitre  in  such  cases,  though  he  had  seen  occasionally  goitrous 
children  without  any  history  of  treatment  by  iodide  of  potassium. 
Dr  Keppie  Paterson  had  mentioned  the  treatment  of  pregnant 
women  with  mercury,  and  had  spoken  of  the  advantage  of 
giving  the  per  chloride.  He,  too,  had  found  that  mercury  had 
a  much  better  effect  than  giving  iodide  of  potassium  alone. 
The  red  iodide  of  mercury  ^  gr.  was  the  preparation  he  used, 
combined  with  iodide  of  potassium  5  gr.,  for  the  purpose  of 
dissolving  it ;  this  could  be  continued  for  long  periods,  and  he 
had  found  it  more  satisfactory  than  the  perchloride.  He  had 
had  the  same  experience  as  Dr  Paterson,  in  finding  that 
patients  taking  the  mercury  became  fatter  and  looked  more 
healthy  and  better  nourished  than  before.  He  added  his  thanks 
to  Dr  Watson  for  his  suggestive  paper. 

The  President  said  there  were  really  two  points  brought  out 
by  Dr  Watson  very  interestingly.  The  first  was,  the  advantage 
of  medicines  given  to  the  mother  during  pregnancy  in  pre- 
venting abortion  and  premature  labour  in  cases  of  syphilis. 
This  case  had  shown  the  benefit  of  potassium  salts,  and  although 
they  did  not  know  how  potassium  chlorate  acted,  clinical  facts 
warranted  its  use.  The  second  point,  as  to  the  relationship 
of  the  enlargement  of  the  foetal  thyroid  to  the  condition  of  the 
mother  and  to  the  medicine  given,  was  quite  a  separate  thing, 
but  exceedingly  interesting.  Personally  he  had  the  growing 
impression  that  there  was  some  connection,  though  it  seemed  to 
be  extraordinary.  The  fact  that  foetal  goitre  was  rare  in  the 
children  of  non-goitrous  parents  must  be  kept  in  mind.  Six 
cases  seemed  a  small  number  to  draw  conclusions  from ;  still  it 
was  a  very  extraordinary  coincidence,  if  it  were  simply  a 
coincidence.     There  was  the  argument  that  iodide  of  potassium 


POTASSIUM   IODIDE,   BY  DR   B.   P.   WATSON.  219 

was  often  given  and  yet  the  child  was  born  without  any  goitre. 
That  raised  the  whole  question  of  placental  transmission.  The 
problem  of  antenatal  therapeutics  was  not  so  simple.  Some 
looked  on  it  as  giving  the  drug  to  the  mother  and  producing 
the  effect  on  the  child.  But  in  giving  the  drug  to  the  mother, 
it  might  alter  in  its  chemistry  in  her  stomach,  it  approached 
the  uterus  through  the  circulation,  in  which  again  it  might  be 
altered;  it  was  almost  certain,  as  demonstrated  by  modern 
research,  that  the  placenta  altered  things  that  passed  through 
it,  and  it  was  not  simply  a  question  of  transudation.  It  then 
reached  the  foetus,  and  the  foetus  itself  might  have  an  effect  on 
it.  Antenatal  therapeutics  was  by  no  means  simply  a  question 
of  forcing  a  drug  into  a  patient's  stomach  in  order  to  have 
a  definite  effect.  Another  point  was,  that  there  was  no  doubt 
that  the  placenta  did  sometimes  allow  substances  to  pass 
through  it,  and  at  another  time  it  would  block  the  same 
substance,  either  through  some  subtle,  chemical,  or  physicial 
change  in  it  or  in  the  syncitium.  He  therefore  did  not  think 
it  right  to  exclude  the  possibility  that  the  drug  given  to  the 
mother  might  have  some  influence  in  producing  enlargement  of 
the  thyroid,  although  not  doing  so  in  every  case.  Certainly 
every  case  should  be  recorded.  A  suggestion  had  been  made 
two  or  three  years  ago  that  they  should  give  mercury  in  these 
cases  in  the  form  of  the  oleate  through  the  vagina,  giving  it 
topically.  There  were  a  great  many  much  more  favourable 
results  when  the  drug  was  absorbed  directly  through  the  tissues, 
reaching  the  placenta  and  foetus  more  directly. 

Br  B.  P.  Watson,  in  reply,  thanked  the  Society  for  the  kind 
way  it  had  received  the  paper.  There  was  really  nothing  he 
could  add,  in  reply  to  the  various  speakers,  to  what  had  already 
been  said  in  the  paper. 


220  EXHIBITION   OF   SPECIMENS. 

Meeting  VIII.— July  10,  1907. 
Dr  J.  W.  Ballantyne,  President,  in  the  Chair. 

I.  The  following  gentleman  was  elected  an  Honorary  Fellow 
of  the  Society: — Dr  med.  Seichu  Kinoshita,  Professor  of 
Gynaecology  and  Obstetrics,  of  Imperial  University,  Tokio, 
Japan. 

II.  Professor  Kynoch  showed — (a)  cervical  fibroid,  weigh- 
ing 12  lbs.  The  patient,  a  nullipara,  set.  48,  had  complained 
of  pelvic  discomfort  for  four  years.  Menstruation  regular  till 
two  years  before  coming  under  observation ;  since  then  it  had 
been  irregular.  Her  chief  complaint  was  intermittent  attacks 
of  retention  of  urine.  On  examination,  the  cervix  was  found 
high  up  and  pressed  against  the  symphysis  pubis.  The  pos- 
terior fornix  was  filled  with  a  hard,  fixed  tumour,  the  upper 
border  of  which  reached  to  about  2  inches  below  the  umbilicus. 
The  fundus  of  the  uterus  was  felt  as  a  knob-like  projection 
above  the  pubes  and  in  front  of  the  cervical  tumour.  On 
opening  the  abdomen  the  main  tumour  was  found  to  be  retro- 
peritoneal. The  posterior  layer  of  peritoneum  was  opened, 
the  tumour  brought  forward,  and  along  with  the  slightly 
enlarged  uterus  was  removed  by  supravaginal  hysterectomy; 
the  peritoneal  opening  being  closed  with  a  continuous  suture. 

(b)  Uterine  fibroid,  complicated  with  pregnancy  at  the 
fourth  month,  removed  by  hysterectomy.  The  patient,  eet.  36, 
complained  of  pelvic  discomfort  and  frequent  micturition  when 
about  four  months  pregnant.  On  examination,  the  cervix  was 
found  directed  to  the  front,  and  the  fundus  reached  half-way  to 
the  umbilicus.  Through  the  posterior  fornix  there  was  felt  a 
hard  movable  tumour  connected  with  the  uterus,  but  much 
harder  in  consistence.  Attempts  to  push  the  tumour  past  the 
sacral  promontory  and  retain  it  there  failed.     As  it  was  obvious 


FIVE  CASES  OF  CESAREAN  SECTION,  BY  PROF.  J.  A.  C.  KYNOCH.    221 

that  the  fibroid  tumour  would  cause  absolute  obstruction  to  the 
passage  of  a  viable  child,  operation  was  decided  on.  As  the 
tumour  was  fairly  movable,  and  thought  therefore  to  be  pedun- 
culated, it  was  hoped  that  its  removal  without  interference  with 
the  pregnant  uterus  could  be  carried  out.  After  its  removal, 
however,  the  bleeding  from  the  uterine  wound  was  so  persistent 
that  it  was  thought  safer  to  complete  the  operation  by  supra- 
vaginal hysterectomy.  Both  patients  made  very  satisfactory 
recoveries. 

III.  Dr  Ballantyne  showed  a  copy  of  an  edition  of  the 
ByrtTi  of  Manhynde  of  nearly  one  hundred  years  later  than  a 
copy  he  had  previously  shown  to  the  Society. 


IV.  A  SERIES  OF  FIVE  CASES  OF  CESAREAN  SECTION 
FOR  CONTRACTED  PELVIS. 

By  John  A.  C.  Kynoch,  M.B.,  F.RC.P.,  F.B.C.S.  (Ed.),  Professor  of 
Obstetrics  and  Gynaecology,  University  of  St  Andrews. 

Since  the  opening  of  the  Dundee  Maternity  Hospital  seven 
years  ago,  there  have  been  admitted  forty-six  cases  of  con- 
tracted pelvis,  which  have  been  treated  as  follows : — 

(1)  Extraction  (breech  presentation)        .  .       1 

(2)  Spontaneous  delivery  (two  premature  labours)  10 

(3)  Forceps  .  .  .  .  .9 

(4)  Version  .  .  .  .  .4 

(5)  Craniotomy     .  .  .  .  .2 

(6)  Induction  of  premature  labour  followed   by 

symphyseotomy  .  ,  .  .1 

(7)  Induction  of  labour  .  .  .  .9 

(8)  Symphseotomy  .  .  .  .3 

(9)  Cesarean  section  .  .  .  .7 

46 


222  FIVE   CASES   OF  CESAREAN   SECTION, 

In  reporting  the  following  five  cases  of  Cesarean  section 
performed  for  contracted  pelvis,  it  is  interesting  to  note  that 
three  of  the  patients  belonged  to  Glasgow,  where  rickets  is  so 
prevalent,  and  consequently  where  so  many  cases  of  pelvic 
deformity  are  met  with. 

The  following  are  the  notes  of  my  cases : — 

Case  I. — J.  Y.,  aged  21,  was  delivered  of  her  first  child 
eighteen  months  before  admission  to  hospital.  She  had  been 
thirty  hours  in  labour,  when  repeated  attempts  to  effect 
delivery  by  forceps  in  Walcher's  position  failed.  Version  was 
then  resorted  to,  and  a  still-born,  slightly  premature  male  child 
was  delivered,  there  being  great  difficulty  in  getting  the  after- 
coming  head  through  the  pelvis.  She  presented  herself  at  the 
Dundee  Maternity  Hospital  on  6th  December  1903,  supposed 
to  be  about  eight  months  pregnant.  She  was  of  feeble  intelli- 
gence, and  consequently  could  give  no  history  relating  to  her 
pregnancy.  The  date  of  her  last  menstruation,  and  of  foetal 
movements,  could  not  be  ascertained.  She  was  of  healthy 
appearance;  lungs,  heart,  and  kidneys  normal.  She  showed 
obvious  signs  of  rickety  deformity.  Her  height  was  4  ft.  4  in., 
and  there  was  antero-posterior  curvature  of  both  tibiae,  less 
marked  in  the  bones  of  the  fore-arm.  The  pelvic  measure- 
ments were  as  follows : — 

Interspinous      .  .  .  .9    ins. 

Intercristal       .  .  .  9      „ 

Diagonal  conjugate       .  .  3f    „ 

True  conjugate  estimated  at  about  3  ins.  The  pelvis  was  of  the 
small,  flat,  rickety  type.  Judging  from  the  height  of  the 
fundus,  the  date  of  pregnancy  corresponded  to  about  the  end  of 
the  eighth  month. 

Forceps  and  version  having  failed  to  deliver  a  living  child 


BY   PKOF.   JOHN   A.   C.    KYNOOH.  223 

in  her  previous  pregnancy,  the  alternative  methods  of  delivery 
were — 

(1)  Induction  of  premature  labour. 

(2)  Craniotomy   (in   the  event  of  forceps  failing   at  full 

time). 

(3)  Symphyseotomy. 

(4)  Caesarean  section. 

Craniotomy  was  at  once  excluded,  for  as  Sangar  has  stated, 
"  the  medical  practitioner  who  does  craniotomy  on  the  living 
child  in  a  case  in  which  the  patient  can  be  removed  to  a 
hospital  in  order  to  undergo  Caesarean  section,  with  preserva- 
tion of  the  child's  life,  has  fallen  behind  the  requirements  of  the 
times." 

The  induction  of  premature  labour  would  have  been 
almost  absolutely  favourable  for  the  mother,  whilst  for  the 
child  the  chances  would  have  been  almost  proportionally 
unfavourable,  brought  up  as  it  would  have  been  in  the  most 
unsanitary  surroundings.  With  regard  to  symphyseotomy,  the 
degree  of  pelvic  contraction  in  this  case  was  perfectly  suitable 
for  this  me'thod  of  delivery.  But  its  immediate  mortality  is 
not  any  lower  than  Caesarean  section  performed  under  the 
most  favourable  conditions.  It  permits  of,  but  does  not 
deliver  the  child,  and  it  prevents  the  patient  being  sterilised,  if 
this  is  deemed  advisable.  With  the  ever-improving  results  of 
the  Caesarean  operation,  the  indications  for  symphyseotomy 
will  probably  come  to  be  narrowed  down  to  cases  where 
forceps  in  Walcher's  position  fail,  instead  of  being  a  recognised 
method  of  delivery  at  a  pre-arranged  date.  The  conditions 
being  favourable,  in  the  interests  of  both  mother  and  child,  for 
Caesarean  section,  and  as  it  was  specially  desirable  in  this  case 
to  prevent  further  pregnancies,  I  decided  to  let  the  patient  go 
on  to  full  time,  and  do  the  operation  at  a  pre-arranged  date. 
On  the  2nd  January,  the  patient  having  been  prepared  as  for 


224  FIVE   CASES   OF   C.ESAKEAN   SECTION, 

an  ordinary  abdominal  section,  and  before  the  onset  of  labour, 
I  performed  Cesarean  section  after  the  method  of  Cameron. 
The  child's  back  was  directed  to  the  left  side,  head  presented, 
heart  sounds  distinct.  The  abdomen  was  opened  in  the  usual 
way,  the  incision  extending  from  an  inch  above  the  umbilicus 
to  2  inches  above  the  symphysis  pubis.  The  uterus  having 
been  fixed  in  a  symmetrical  position,  it  was  surrounded  by 
large  flat  sponges.  A  flat  vulcanite  pessary  was  placed  in  the 
middle  line  below  the  fundus,  and  pressed  on,  in  order  to  permit 
of  the  uterus  being  opened  with  a  minimum  loss  of  blood. 
The  membranes  being  exposed,  the  uterine  incision  was 
extended  downwards,  the  membranes  ruptured,  and  the  child 
delivered  head  first,  the  placenta  attached  to  the  posterior 
uterine  wall  being  easily  detached.  The  uterus  was  then 
turned  out  of  the  abdomen,  the  edges  of  the  incision  everted, 
and  the  upper  and  lower  angles  compressed  by  an  assistant. 
Eight  deep  and  six  superficial  silk  sutures  were  inserted  into 
the  uterine  wound,  the  mucosa  not  being  included.  The 
Fallopian  tubes  were  then  tied  in  two  places  and  divided. 
The  uterus  responded  well  to  sponge  pressure,  and  contracting 
satisfactorily,  it  was  returned  into  the  abdomen,  and  the 
abdominal  incision  closed  by  through  and  through  silkworm 
gut  sutures.  The  child,  a  female,  weighing  6  lbs.  12  oz.,  was 
slightly  asphyxiated,  but  soon  responded  to  artificial  respira- 
tion. With  the  exception  of  a  rise  of  temperature  to  101°  on 
the  second  day,  the  after  progress  of  the  case  was  an  absolutely 
satisfactory  one.  The  child  was  put  to  the  breast  at  the  end 
of  a  week,  and  was  nursed  throughout  the  period  of 
convalescence. 

Case  II. — Mrs  G-.,  aged  21,  primipara,  came  under  my 
observation  on  the  16th  February  1906.  She  stated  that  labour 
had  been  in  progress  for  about  twenty-four  hours,  and  that  the 
membranes  ruptured  soon  after  labour  began.     She  was  a  very 


BY   PROF.    JOHN   A.    C.    KYNOCH.  225 

small  woman,  with  marked  curvature  of  the  bones  of  the  legs. 
Her  general  condition  was  satisfactory,  and  beyond  a  slight 
trace  of  albumen  in  the  urine,  the  various  systems  were  normal, 
pulse  84.     Pelvic  measurements : — 

Interspinous      .  .  .  8J  ins. 

Intercristal        .  .  .  .  8      „ 

Diagonal  conjugate  .  .  .  3      „ 

True  conjugate  under  .  .  .  2|    „ 

The  child's  back  was  directed  to  the  right  side,  head  movable 
above  the  brim  in  the  transverse  diameter,  and  the  os  half 
fully  dilated.  Cesarean  section  being  decided  on,  the  operation 
was  performed  as  in  the  previous  case.  The  placenta  was 
attached  to  the  anterior  uterine  wall.  The  child — female — 
mature,  weighing  6  lbs.,  was  nursed  during  convalescence,  and 
both  left  hospital  well,  three  weeks  after  operation.  It  was 
ascertained  later,  however,  that  the  child  had  died  when  two 
months  old. 

Case  III. — Mrs  C,  aged  26,  ii.-para,  was  admitted  to  the 
Maternity  Hospital  on  24th  January  1906,  at  the  eighth  month 
of  pregnancy.  The  history  given  by  her  doctor  was  that  she 
was  delivered  of  her  first  child  in  September  1904.  She  had 
been  long  in  labour  before  sending  for  assistance.  Attempts 
to  deliver  with  forceps  having  failed,  craniotomy  was  resorted 
to,  and  with  great  difficulty  the  child  was  pulled  through  the 
contracted  pelvis.  She  was  sent  to  hospital  as  a  case  suitable 
for  Cesarean  section.  She  was  of  healthy  appearance,  her 
height  was  4  feet  6  inches.  She  had  a  wabbling  gait,  and  there 
was  slight  curvature  of  the  bones  of  both  legs.  The  pelvic 
measurements  were  as  follows : — 

Interspinous      .  .  .  7f  ins. 

Intercristal        ....  8-J-    „ 

Diagonal  conjugate        .  .  3 J    „ 

True  conjugate  .  .  .  .  2|    „ 


226  FIVE   CASES  OF   CESAREAN   SECTION, 

It  was  decided  to  keep  her  in  hospital  till  full  time,  and  to 
operate  at  a  pre-arranged  day  and  hour. 

At  10  A.M.,  on  21st  February,  and  before  the  onset  of  labour, 
Csesarean  section  was  performed,  the  steps  of  the  operation 
being  the  same  as  in  the  previous  cases.  After  the  removal  of 
the  placenta  and  membranes  I  passed  my  finger  into  the  cervix 
from  above,  in  order  to  be  satisfied  as  to  the  patency  of  its 
canal.  This  I  found  to  be  very  considerably  stenosed,  as  a 
consequence  probably  of  injuries  received  during  the  mani- 
pulations necessary  to  effect  delivery  at  the  first  confinement. 
I  then  passed  a  uterine  sound  through  the  cervix  and  closed 
the  uterine  wound.  At  first  there  was  pretty  copious  bleeding 
through  the  cervical  canal,  but  with  the  application  of  continuous 
sponge-pressure  the  uterus  contracted  satisfactorily.  Both 
tubes  were  ligatured  and  divided.  Ergo  tin  was  given  hypoder- 
mically  immediately  before  and  after  operation.  The  child,  a 
male,  weighed  6J  lbs.,  and  left  the  hospital  well. 

The  patient's  condition  remained  satisfactory  during  the 
first  forty-eight  hours  after  operation.  After  this  she  got 
restless.  Pulse  became  quicker,  and  she  died  on  the  evening 
of  the  fourth  day  with  all  the  signs  and  symptoms  of  septic 
peritonitis.  At  the  post-mortem  all  the  uterine  sutures  were 
intact,  but  the  upper  two  had  become  infected,  as  shown  by  the 
presence  of  pus  in  their  track. 

Case  IV. — Mrs  Nsl  primipara,  aged  31,  was  admitted  to  the 
Maternity  Hospital  at  midnight  on  27th  December  1906, 
having  been  in  labour  for  seven  hours.  Except  for  chronic 
dyspepsia  her  previous  health  had  been  good,  and  the  examina- 
tion of  the  various  systems  (beyond  a  trace  of  albumen  in  the 
urine)  presented  nothing  abnormal.  Temperature  normal,  pulse 
76,  and  general  condition  satisfactory.  On  pelvic  examination, 
the  cervix  was  found  dilated  to  the  size  of  a  five-shilling  piece, 
membranes  ruptured,  and  the  head  was  lying  above  the  pelvic 


BY   PROF.    JOHN   A.    C.    KYNOCH.  227 

brim  in  the  transverse  diameter.  The  pelvic  measurements 
were  as  follows : — 

Inter  spinous      .  .  .  .9    ins. 

Intercristal        .  .  .                    10    „ 

Diagonal  conjugate  .  .                    3J     „ 

True  conjugate  .  .  .                    2f    „ 

Cesarean  section  was  performed  as  in  the  previous  cases.  The 
child  weighed  6  lbs.,  and  measured  20  inches.  On  31st 
January  the  urine  was  free  from  albumen.  Both  mother  and 
child  progressed  favourably,  and  left  the  hospital  on  5th 
February. 

Case  V. — E.  M.,  primipara,  aged  22,  was  admitted  to 
hospital  in  labour  on  23rd  February  1907.  She  was  of  healthy 
appearance,  her  height  was  4  feet  3  inches,  and  there  was  well- 
marked  lumbar  lordosis  and  curvature  of  both  tibiae.  Examina- 
tion of  the  various  systems  presented  nothing  abnormal.  The  os 
was  dilated  to  the  size  of  a  half-crown  piece,  and  the  membranes 
were  unruptured.     The  pelvic  measurements  were  as  follows : — 

Interspinous      .  .  .  .8    ins. 

Intercristal        .  .  .  9      „ 

Diagonal  conjugate  .  .  3 J    „ 

True  conjugate .  .  .  .       2f    „ 

Cesarean  section  was  performed  as  in  previous  cases.  The 
child  (male)  weighed  6  lbs.  12  oz.,  and  measured  19  inches. 

Both  mother  and  child  made  satisfactory  recoveries,  and 
left  the  hospital  on  5th  April. 

There  are  a  few  points  connected  with  this  operation  which 
the  experience  of  these  cases  suggests.  First,  a  comparison  of 
the  methods  of  treating  the  uterus  after  delivery  of  the  child, 


228  FIVE  CASES   OF   CESAREAN   SECTION, 

and  these  are — (a)  Hysterectomy  (partial  or  complete);  (b) 
Retention  of  the  uterus,  with  sterilisation,  either  by  division  or 
resection  of  the  tubes ;  (c)  Leaving  the  uterus  without  sterilisa- 
tion, the  true  conservative  operation.  Each  method  has  its 
advocates.  With  regard  to  the  ethics  of  sterilisation  there  are 
two  conflicting  opinions.  On  the  one  hand,  we  have  authorities 
who  think  that  the  question  is  one  for  the  patient  to  decide  ;  on 
the  other  hand,  there  are  those  who  hold  that  the  operator 
should  restore  the  patient  to  as  normal  a  condition  as  possible, 
omitting  any  method  of  sterilisation,  and  repeating  the  operation 
of  Cesarean  section  if  occasion  should  arise.  The  first  case 
which  I  have  reported  is  one  where  it  would  have  been  unwise 
to  leave  the  decision  to  the  patient,  as  her  intelligence  was  so 
feeble  as  to  prevent  her  being  able  to  look  after  herself  properly, 
far  less  a  family.  The  second  case,  however,  where  the  patient 
was  sterilised  at  the  time  of  operation  and  where  the  child  died 
when  two  months  old,  would  favour  the  proposal  that  sterilisa- 
tion might  with  advantage  be  deferred  until  a  second  child  had 
been  delivered  by  Cesarean  section.  Granted  that  the  patient 
is  intelligent  enough  to  understand  the  situation,  and  that  she 
is  willing  to  undertake  the  risk  of  a  second  operation,  then 
sterilisation  may  be  omitted  at  the  first  operation.  Many  cases 
are  now  reported  where  the  operation  has  been  repeated  success- 
fully two,  three,  and  four  times  on  the  same  patient.  Yet  I 
hold  that  it  is  not  justifiable  to  endeavour  to  break  the  record 
of  the  well-known  case  of  Frau  Eittgen,  whose  pluck  in  sub- 
mitting to  Csesarean  section  five  times  led  to  a  fatal  termination 
at  the  fifth  repetition  of  the  operation.  In  all  the  cases  I  have 
reported  the  patients  were  sterilised  by  ligature  and  division  of 
the  tubes.  This  I  consider  a  reliable  enough  method,  and  safer 
to  the  patient  than  hysterectomy,  which  1  think  should  be 
restricted  to  cases  of  atony  and  suspected  infection  of  the 
uterus.  Another  question  which  suggests  itself  is,  What  is  the 
best  time  to  operate  ?     In  three  of  my  cases  labour  had  already 


BY   PltOF.   JOHN   A.    C.    KYNOCH.  229 

commenced,  and  in  two  the  operation  was  performed  at  a  pre- 
arranged date,  and  before  the  onset  of  labour.  Those  who 
recommend  waiting  till  labour  has  begun,  do  so  because  they 
think  there  is  less  chance  of  haemorrhage  from  uterine  atony, 
and  that  a  dilated  condition  of  the  cervix  ensures  freer  escape 
of  the  lochial  discharge.  The  first  fear  is  groundless,  for  the 
uterus  contracts  quite  as  well  before  as  after  the  onset  of 
labour.  That  a  dilated  condition  of  the  cervical  canal  is  of  the 
greatest  importance,  is  shown  by  my  unsuccessful  case.  Here 
the  cervical  canal  was  so  stenosed  as  only  to  admit  a  uterine 
sound,  and  although  this  appeared  to  be  sufficient  to  permit  of 
escape  of  the  lochial  discharge,  as  shown  by  the  occurrence  of 
pretty  free  bleeding  after  the  operation,  yet  I  feel  convinced 
that  if  dilatation  of  the  cervix  up  to  the  size  of  a  two-shilling 
piece  had  preceded  Caesarean  section,  the  case  would  have  run 
as  favourable  a  course  as  the  others.  In  my  first  two  cases  I 
incised  the  uterine  wall  between  the  bars  of  a  flat  vulcanite 
pessary,  as  recommended  by  Cameron,  to  diminish  the  haemor- 
rhage during  the  uterine  incision ;  but  I  discarded  it  in  my  other 
cases,  and  did  not  find  any  marked  difference  in  the  amount  of 
bleeding  as  a  result.  Further,  haemorrhage  during  the  operation 
I  have  found  to  be  best  controlled  by  an  assistant  grasping  the 
broad  ligaments,  and  subsequently  maintaining  uterine  con- 
traction by  sponge-pressure.  In  all  my  cases  the  uterine 
incision  was  a  vertical  one,  and  so  far  as  I  am  aware  the  trans- 
verse incision  of  Fritsch  does  not  seem  to  have  proved  itself  in 
any  way  superior.  Lastly,  with  sterilised  towels  well  packed 
round  the  uterus,  it  is  not  necessary  to  adopt  Muller's  suggestion 
of -eventrating  the  uterus  before  opening  it,  as  this  involves  a 
very  large  abdominal  incision.  But  after  the  uterus  has  been 
emptied  of  its  contents,  and  as  a  consequence  diminished  in 
bulk,  the  introduction  of  the  uterine  sutures  is  facilitated  by 
bringing  the  uterus  outside  the  abdomen. 


230  FIVE  CASES   OF  CESAREAN   SECTION, 

Br  Barbour  said  they  were  very  much  indebted  to  Professor 
Kynoch  for  the  extremely  interesting  paper,  and  congratulated 
him  very  heartily  on  the  success  of  his  cases.  In  Edinburgh 
they  had  not  so  many  cases  of  contracted  pelvis,  and  there- 
fore their  experience  in  the  Maternity  Hospital  here  was 
limited.  He  quite  agreed  with  Professor  Kynoch  in  all  the 
points  he  had  raised.  He  thought  he  was  right  in  saying  that 
the  best  time  for  operation  was  before  labour  was  begun.  He 
thought  he  was  also  right  as  to  the  sterilisation  of  the  patient. 
Unless  the  patient  herself  was  very  anxious  to  undergo  the 
operation  a  second  time,  he  thought  they  ought  to  do  the  best 
thing  for  the  mother ;  and  as  there  was  a  certain  risk  in  the 
operation  of  Cesarean  section,  and  if  they  secured  the  one 
living  child,  they  had  done  all  they  were  justified  in  aiming  at. 
With  regard  to  the  question  of  the  cause  of  death  in  the  case 
that  had  died.  It  was  an  interesting  case.  He  was  not  quite 
clear  that  the  infection  had  started  from  the  uterine  cavity — 
the  sutures  had  not  been  passed  through  the  mucosa.  In  all 
the  cases  mentioned,  the  average  amount  of  the  contraction 
seemed  to  be  about  2 j  inches.  He  thought  Professor  Kynoch 
was  also  right  in  declaring  in  favour  of  Cesarean  section  rather 
than  symphyseotomy.  He  had  not  had  any  experience  of 
symphyseotomy,  but  in  one  case  of  pubotomy  the  convalescence 
had  been  very  protracted.  Caesarean  section  was  undoubtedly 
the  preferable  operation.  He  was  also  interested  to  hear  that 
the  patients  were  able  to  nurse  their  children. 

Dr  Munro  Kerr  had  been  specially  interested  in  this  report 
of  cases  of  Cesarean  section,  because  they  had  so  many  of 
them  in  the  Glasgow  Maternity  Hospital.  It  was  specially 
interesting  that  three  of  the  cases  were  from  Glasgow.  Professor 
Kynoch  had  raised  a  number  of  interesting  points.  He  would 
be  pardoned  if  he  spoke  for  rather  longer  than  usual  on  one 
or  two  of  the  points,  for  he  was  now  speaking  from  an  experi- 
ence of  fifty-four  cases  of  the  operation.     First,  as  to  the  time 


BY  PROF.   JOHN  A.    C.   KYNOCH.  231 

of  the  operation.  He  had  not  found  it  had  made  much  differ- 
ence whether  the  operation  was  performed  during  or  before 
labour.  In  primiparse  there  had  sometimes  been  difficulty  and 
discomfort  from  after-pains,  which  looked  as  if  the  patients 
had  been  suffering  from  retention  of  the  lochial  discharge.  So 
much  had  these  cases  impressed  him  that  in  primiparse  now  he 
waited,  if  possible,  till  labour  had  commenced.  In  multipara 
he  always  arranged  to  operate  before  labour  had  begun.  From 
his  experience  he  would  say  that  Professor  Kynoch  was  quite 
right  in  saying  that  after  emptying  the  uterus  before  labour 
commenced  there  was  seldom  any  bleeding,  and  in  only  one  of 
his  cases  had  there  been  excessive  bleeding  that  could  not  be 
controlled,  and  which  had  necessitated  the  removal  of  the 
uterus.  This  case  had  been  brought  from  the  country,  some 
seventeen  miles,  and  had  been  in  labour  some  hours  before  she 
started  her  journey.  She  was  considerably  exhausted  by  the 
journey  and  by  continuous  uterine  contractions.  In  all  his 
other  cases  there  had  been  no  post-partum  haemorrhage;  the 
uterus  had  contracted  well.  With  regard  to  the  abdominal 
incision,  Professor  Kynoch  had  described  what  used  to  be  the 
custom — making  the  incision  from  about  an  inch  above  the 
umbilicus  down  to  within  about  an  inch  of  the  symphysis. 
He  thought  this  was  a  mistake,  and  most  modern  operators 
made  the  incision  as  high  as  possible,  so  as  to  cut  into  the  upper 
part  of  the  uterus  and  avoid  any  approach  to  the  lower  uterine 
segment.  With  the  old  incision,  in  extracting  the  child,  if  the 
incision  was  not  quite  large  enough,  one  might  get  a  nasty  tear 
of  the  lower  uterine  segment.  Consequently  there  was  great 
advantage  in  opening  the  uterus  high.  Further,  with  the 
high  wound  there  was  better  union  and  less  chance  of  hernia. 
With  regard  to  the  delivery  of  the  child,  Professor  Kynoch  had 
mentioned  delivery  by  the  head  first,  but  Dr  Munro  Kerr 
had  found  it  much  easier  to  seize  the  legs  and  extract  by  the 
legs.     A  rather  important  point  was  the  turning  out  of   the 


232  FIVE    CASES    OF   CESAREAN   SECTION, 

uterus  before  opeuing  it,  or  openiug  it  as  it  lay  in  the  abdominal 
cavity.     He  thought  what  Professor  Kynoch  had  said  as   to 
packing  round  with  towels  prevented  the  necessity  of  turning 
it   out   at    all.      If   it  were   turned   out,  a  larger   abdominal 
incision  was  necessary.     The  only  cases  in  which  he  thought  it 
was  advisable  to  turn  out  the  uterus  were  those  cases  where 
the  membranes  had  ruptured  some  time  before.     In  such  cases 
it  was  a  distinct  advantage  to  turn  it  out  and  pack  round  with 
sterilised  towels,  and  open.     In  some  of  these  cases  he  had 
actually  not  removed  the  placenta  through  the  uterus,  but  had 
pushed  it  out  through  the  vagina,  and  as  far  as  possible  swept 
everything  downwards.     In  opening  the  uterus,  he  had  quite 
given  up  the  pessary.     It  was  really  quite  unnecessary.     It 
was  of  no  value  where  the  placenta  was  attached  anteriorly. 
It  certainly  did  slightly  control  the  bleeding  when  the  placenta 
was  attached  posteriorly,  but  was  not  in  the  least  necessary. 
All  other  writers,  in  recent  years,  on  Cesarean  section,  were  of 
the  same  opinion.     As  to  the  question  of  sterilisation,  it  was 
very  difficult  to  express  an  opinion.     The  ethical  question  was 
a  very  subtle  one,  and  he  was  not  prepared  to  take  up  any 
position  regarding  it.     In  a  sense,  as  medical  men  they  were  not 
concerned  with  anything  but  doing  the  best  for  the  patient. 
They  were  not  concerned  with  future  pregnancies ;  that  was  for 
her  husband  and  herself  to  decide.     He  thought  there  was  a 
good  deal  to  be  said  for  those  who  took  up  the  rational  position, 
and  said  a  woman  should  not  be  sterilised.     Still,  on  the  other 
hand,  as  an  ordinary  human  being,  he  felt  sorry  for  a  woman 
who  had  to  have  her  abdomen  opened  several  times.     There 
was  no  doubt  that,  if  she  went  on  having  her  abdomen  opened 
time  after  time,  she  would  die  from  the  operation ;  that  is  to 
say,  her  chances  of  dying  were  increasing  each  time.     It  was 
not  correct  to  say  that  one  could  open  the  abdomen  repeatedly 
without  opening  the  peritoneal  cavity,  because  it  was  shut  off 
by  adhesions.     In  five  or  six  such  cases  he  had  had,  in  only  one 


BY  PROF.   JOHN   A.    C.    KYNOCH.  233 

case  was  the  peritoneal  cavity  completely  shut  off,  and  he  was 
able  to  open  into  the  uterus  extra -peritoneally.  In  the  other 
cases  it  had  been  quite  impossible  to  open  the  uterus  without 
opening  into  the  peritoneum.  In  this  connection  he  would 
mention  two  patients  who  had  come  to  him  after  being 
sterilised  by  having  their  tubes  tied  and  cut,  who  had  each  of 
them  lost  their  children.  In  the  first  case  he  had  said  that 
nothing  could  be  done,  that  there  was  no  further  chance  of 
her  becoming  pregnant.  In  the  second  case  he  was  prepared 
to  resect  the  ends  of  the  tied  tubes,  and  try  to  make  a 
permanent  passage  again  between  the  uterus  and  the  ovary. 
He  had  not  said  this  on  the  off-chance  of  it  being  successful, 
but  because  he  had  seen  two  cases  where  the  abdomen  had  been 
opened  subsequently  to  Cesarean  section  in  which  the  tubes 
had  been  tied,  and  the  tubes  were  found  quite  patent.  The 
silk  had  cut  through  the  tubes,  and  in  both  of  these  cases  it 
would  have  been  possible  to  have  joined  together  the  ends  of 
the  tubes,  with  a  great  probability  of  establishing  a  permanent 
passage  between  the  uterus  and  the  ovary  again.  That  was  his 
only  reason  for  sterilising  by  tying  the  tubes,  and  not  by 
removing  the  uterus.  He  did  not  agree  with  Professor  Kynoch 
that  it  was  a  safer  operation  to  leave  the  uterus  behind ;  he 
thought  that  the  safest  operation  and  the  one  that  gave  the 
best  results  was  that  of  removing  the  uterus.  In  taking  away 
the  uterus,  all  the  dangers  of  the  puerperium  were  removed, 
and  the  operation  was  not  a  difficult  one,  especially  if  the 
woman  was  not  in  labour,  and  the  cervical  canal  had  not 
become  dilated.  If  the  patient  were  in  labour,  and  the  canal 
become  dilated,  there  was  a  large  stump  to  stitch  up  and  close, 
and  the  operation  was  then  a  little  more  complicated.  As 
regards  the  position  of  Caesarean  section  and  symphyseotomy, 
he  entirely  agreed  with  Dr  Kynoch  and  Dr  Barbour  that 
Caesarean  section  was  preferable,  and"  he  thought  Professor 
Kynoch  had  put  the  position  of  symphyseotomy  in  exactly  the 


234  FIVE  CASES   OF   CESAREAN   SECTION, 

right  way,  namely,  that  it  should  be  reserved  for  these  cases 
where  one  just  failed  to  deliver  with  forceps.  The  amount  of 
pelvic  contraction  should  be  carefully  estimated,  and  then 
forceps  should  be  tried,  and  if  one  found  one  wanted  a  little 
more  room,  then  symphyseotomy  might  be  done.  He  had  had 
nine  cases  of  symphyseotomy,  and  had  never  seen  any  trouble 
afterwards  in  locomotion,  and  all  the  children  had  been 
delivered  alive;  and  only  one  of  his  patients  had  had  a  bad 
urethral  tear  (a  primipara) ;  the  others  had  made  a  satisfactory 
recovery.  He  believed  the  reason  was  that  he  had  chosen 
these  cases  with  very  great  care.  As  to  his  results  from 
Csesarean  section,  the  maternal  mortality  in  fifty-four  cases 
was  5  9  per  cent.  The  foetal  mortality — one  child  had  died, 
and  a  second  had  died  in  hospital — giving  an  early  and  late 
mortality  of  2  out  of  54,  or  3*7  per  cent. 

Dr  Lamond  Lackie  said  his  experience  of  the  operation  was 
limited,  for  though  he  had  assisted  several  times  at  the  operation 
he  had  had  only  one  case  of  his  own.  For  that  he  was  indebted 
to  Dr  Haultain,  who  during  his  last  term  of  duty  at  the 
Maternity  Hospital  allowed  Dr  Lackie  to  do  the  operation. 
The  indication  was  deformed  pelvis,  and  the  conservative 
operation  was  performed.  On  the  following  day  the  patient 
had  acute  pneumonia,  and  was  dangerously  ill  for  a  week.  The 
abdominal  wound  became  septic,  and  this  took  months  to  heal, 
but  now  the  patient  was  well.  Dr  Lackie  agreed  with  what 
had  been  said  about  sterilising  the  patient ;  in  the  majority  of 
cases  it  was  desirable.  He  had  listened  with  great  interest  to 
the  record  of  Professor  Kynoch's  series  of  cases. 

Dr  Ritchie  asked  what  sutures  had  been  used. 

Dr  Kynoch  replied  that  he  had  used  silk. 

Dr  Munro  Kerr  used  catgut — size  1  or  2 ;  at  first,  catgut 
sterilised  by  Jellett's  method — later,  Van  Horn's. 

The  President  wished  to  refer  to  one  or  two  points.  As  to 
closing  the  incision,  long  ago  they  used  to  have  successful  cases 


BY  PROF.  JOHN  A.  C.  KYNOCH.  235 

with  no  closure  of  the  uterine  incision  at  all.  He  remembered, 
some  years  ago,  that  a  writer  from  Italy  sent  to  him  for  details 
of  the  operation  as  performed  here,  and  one  of  the  questions 
was  as  to  whether  the  incision  was  closed  here.  He  said  it 
had  been  a  common  thing  not  to  close  the  incision  with  them, 
and  the  patients  had  made  a  good  recovery.  He  had  intended 
to  have  dwelt  a  little  on  the  legal  aspect  of  sterilisation,  but  as 
Professor  Kynoch  had  to  leave  to  catch  a  train,  he  would  not 
now  speak  upon  it. 

Professor  Kynoch,  in  reply,  said  he  was  very  much  obliged 
to  the  Fellows  who  had  spoken.  He  did  not  read  the  paper 
thinking  that  he  had  in  so  few  cases  anything  original  to  say, 
but  because  of  the  opportunity  of  raising  some  questions  in 
connection  with  the  operation.  There  was  one  point  to  which  he 
would  refer  regarding  his  unsuccessful  case.  Dr  Barbour  had 
asked  if  his  sutures  had  included  the  lining  membrane  of  the 
uterus.  They  had  not  done  so,  and  it  was  a  question  whether 
the  retention  of  the  lochial  discharge  or  infection  of  the  suture 
employed  was  the  cause  of  the  sepsis.  That  would  be  a  point 
which  would  be  greatly  in  favour  of  sterilisation  by  means  of 
hysterectomy.  At  the  same  time,  Dr  Kerr,  with  his  large 
experience,  insisted  upon  a  certain  amount  of  dilatation  of  the 
cervix,  so  that  this  must  be  a  point  of  great  importance  in 
the  success  of  the  operation. 


[the  "bykth  of  mankynde.' 


236  THE  "BYRTH  OF  MANKYNDE, 

V.  THE  "BYRTH  OF  MANKYNDE." 

(Its  Contents.) 

By  J.  W.  Ballantyne,  M.D.,  F.R.C.P.  (Edin.),  F.R.S.  (Edin.),  Lecturer 
on  Midwifery  and  Diseases  of  Women,  Surgeons'  Hall  and  Medical 
College  for  Women,  Edinburgh ;  Physician  to  the  Royal  Maternity 
Hospital,  Edinburgh  j  and  President  of  the  Edinburgh  Obstetrical 
Society. 

I  have  already x  dealt  with  the  author  and  the  editions  of  the 
remarkable  book  known  as  the  Byrth  of  Mankynde  ;  and  I  now 
intend  to  complete  the  consideration  of  the  subject  by 
discussing  the  contents  of  the  work  and  the  light  thus  thrown 
upon  sixteenth  century  midwifery.  Before  I  do  so,  how- 
ever, let  me  remind  the  reader  that  Eaynalde's  Byrth  of 
Mankynde  is  really  a  composite  work,  for  it  contains  an  English 
translation  (by  Eichard  Jonas)  of  Eosslin's  Be  Partu  Hominis, 
along  with  new  matter  added  by  Thomas  Eaynalde.  It  has, 
therefore,  three  component  parts :  Eosslin's  Be  Partu  Hominis 
as  translated  by  Jonas,  his  additions  thereto,  and  those  which 
came  from  the  pen  of  Eaynalde.  In  such  a  late  edition  as  that 
of  1654,  a  fourth  element  is  found  in  the  supplementary 
matter  added  by  a  seventeenth  century  editor  whose  name  we 
do  not  know ;  but  it  is  small  in  amount,  consisting  chiefly  of 
directions  for  the  nursing  of  children,  and  no  further  reference 
will  be  made  to  it. 

For  purposes  of  description  I  might  have  taken  any  one  of 
the  first  four  Eaynalde  editions  (those  of  1545,  1552,  1560, 
and  1565),  for  it  is  probable  that  they  all  appeared  during  the 
lifetime   of    Eaynalde;2    but   I   have    chosen   that   of    1560, 

1  Edin.  Obstet.  Trans.,  vol.  xxxi.,   pp.  232-270,  1905-06. 

2  Raynalde  is  not  likely  to  have  been  alive  when  the  1598  edition 
appeared. 


BY  DR   J.    W.    BALLANTYNE.  237 

for  it  represents  what  was  practically  the  final  recension  of  the 
work,  and  does  not  differ  (save  only  in  spelling  and  minor 
details)  from  so  late  an'  edition  as  that  of  1654.  The  quotations 
which  occur  throughout  this  article  are,  therefore,  to  be  regarded 
as  taken  from  the  1560  edition  except  when  it  is  otherwise 
stated.  At  the  same  time,  I  shall  now  and  again  refer  to 
differences  existing  between  the  various  editions,  which  may 
appear  to  have  an  interest  other  than  the  merely  typographical 
and  orthographical;  and  I  shall  draw  attention  to  the  very 
marked  differences  which  are  revealed  by  a  collation  of  Jonas's 
edition  of  1540  with  those  edited  by  Eaynalde  from  1545 
onwards.  Further,  when  I  reach,  in  the  description,  the  part 
of  the  book  which  is  a  translation  of  Eosslin's  Be  Partu 
Hominis,  I  shall  devote  some  space  to  the  consideration  of 
this  German  obstetrician's  life  and  work. 

The  contents  of  Eaynalde's  Byrth  of  Mankynde,  it  need 
hardly  be  said,  have  a  special  interest  for  obstetricians.  The 
book  stands,  so  to  say,  between  the  old  and  the  new  in 
obstetrics :  empiric  midwifery  was,  in  1540,  beginning  to  give 
way  before  the  advance  of  scientific  obstetrics,  although  many 
years  had  still  to  pass  before  the  knowledge  of  the  anatomy 
and  physiology  of  labour  and  the  principles  of  anaesthesia  and 
asepsis  were  to  sweep  away  the  practices  begotten  of  ignorance 
and  superstition.  The  year  1550,  in  which  Pare  introduced 
podalic  version  into  obstetric  practice,  has  usually  been  regarded 
as  marking  the  separation  between  the  midwifery  of  the  past 
and  that  of  the  present ;  if  this  be  so,  then  Eaynalde's  Byrth  of 
Mankynde  appeared  at  the  very  time  when  the  great  transition 
from  the  empiric  methods  of  the  ancients  to  the  scientific 
procedures  of  the  moderns  was  being  brought  about.  It  cannot 
fail  to  be  a  matter  of  the  most  intense  interest  to  know  what 
were  the  practices  and  principles  of  midwifery  in  England  in 
the  middle  of  the  sixteenth  century,  and  we  find  them  both 
revealed  to  us  in  Eaynalde's  book. 


238  THE   "BYRTH   OF   MANKYNDE, 


The  Preliminary  Matter. 


The  preliminary  matter  in  a  typical  Kaynalde  edition  of 
the  Byrth  of  Mankynde  (such  as  that  of  1560)  consists  of  the 
title  page,  the  Aristarchus  preface,  and  the  table  of  contents. 
In  the  single  Jonas  edition  of  1540  there  is  the  title  page,  the 
religious  admonition,  the  dedication  to  Queen  Catherine,  the 
table  of  contents,  and  a  table  of  weights  and  measures. 

The  Title  Page  differs  little,  so  far  as  wording  is  concerned, 
in  the  various  editions  prior  to  that  of  1654.  That  of  the  1560 
edition  reads  as  follows : — "  The  Byrth  of  ||  mankynde,  other- 
wyse  na  ||  med  the  womans  ||  Booke.  ||  Newly  set  foorth,  corrected 
and  ||  augmented:  whose  contentes  ye  ||  may  reade  in  the  Table 
of  the  ||  Booke,  and  most  playne  ||  ly  in  the  Pro  ||  logue.  ||  By 
Thomas  Kaynalde  ||  Physition  ||  1560."  The  titles  of  the  1545 
and  1552  editions  are  similar,  and  no  alteration  of  note 
appears  until  1598,  when  the  title  reads:  "The  birth  of 
man  ||  kinde,  otherwyse  ||  named  the  Wo  ||  mans  Booke.  ||  Set 
foorth  in  English  by  Tho  ||  mas  Eaynalde  Phisition,  and  ||  by 
him  corrected,  and  aug  ||  mented.  Whose  con  ||  tents  yee  may 
reade  ||  in  the  Table  fo  ||  lowyng:  ||  but  most  playnely  in  ||  the 
prologue."  One  or  two  slight  differences  are  to  be  noted  in 
the  editions  of  1604,  1613,  1626,  and  1634,  and  then  there 
occurs  the  radical  change  of  the  1654  edition  (see  Plate  XIV. 
in  my  previous  article,  loc.  eit.,  p.  266). 

The  wording  of  the  title  page  of  the  Jonas  edition  is,  as 
might  be  expected,  somewhat  different :  "  The  Byrth  of  Man- 
kynde, newly  translated  out  of  Laten  into  Englyssha  In  the 
which  is  entreated  of  all  suche  thynges  the  which  chaunce  to 
women  in  theyre  labor,  and  all  suche  inf yrmities  whiche  happen 
unto  the  Infantes  after  they  be  delyuered.  And  also  at  the 
latter  ende  or  in  the  thyrde  or  last  boke  is  entreated  of  the 
Conception  of  mankynde,  and  howe  manye  wayes  it  may  be 
letted  or  furtheryd,  with  diuers  other  fruytefull  thynges,  as 


BY   DR   J.    W.    BALLANTYNE.  239 

doth  appere  in  the  table  before  the  booke.     Cum  privilegio 
Kegali,  ad  imprimendum  solum." 

The  ornamental  border  of  the  title  page  differs  greatly  in 
the  different  editions  which  were  published  before  that  of  1654, 
in  which  it  entirely  disappears ;  but  with  this  matter  I  have 
already  dealt  fully  in  my  first  article  (loc.  cit.). 

The  reverse  side  of  the  title  page  contains  (in  the  1560 
edition)  a  short  Preface,  in  English,  commending  the  work  in 
modest  terms  to  midwives  and  matrons.  The  same  preface 
appears  in  Latin  in  the  1545  and  1552  editions,  and  in  English 
in  all  the  others,  but  it  is  not  always  printed  on  the  reverse 
side  of  the  title  page.  I  have  reproduced  it  in  Plates  II.  and 
XIII.  of  my  former  article,  both  in  its  Latin  and  in  its  English 
form.  Since  it  begins  "Albeit  some  Aristarchus,"  I  have 
named  it  the  Aristarchus  Preface. 

The  Aristarchus  Preface  is  absent  from  the  Jonas  edition 
of  1540 ;  but,  occupying  the  corresponding  position,  there  is  a 
religious  admonition  which  reads  as  follows  (in  ordinary 
English) :  "  Unto  the  Header.  An  admonition  to  the  reader. 
For  so  much  as  we  have  enterprised  the  interpretation  of  this 
present  book,  offering  and  dedicating  it  unto  our  most  gracious 
and  virtuous  Queen  Katherine  only,  by  it  minding  and  tending 
the  utility  and  wealth  of  all  women,  as  touching  the  great 
peril  and  dangers  which  most  commonly  oppresseth  them  in 
their  painful  labours,  I  require  all  such  men  in  the  name  of 
God,  which  at  any  time  shall  chance  to  have  this  book,  that 
they  use  it  godly  and  only  to  the  profit  of  their  neighbours, 
utterly  eschewing  all  ribald  and  unseemly  communications  of 
any  things  contained  in  the  same,  as  they  will  answer  before 
God,  which,  as  witnesseth  Christ,  will  require  a  count  of  all 
their  words,  and  much  more  then  of  all  ribald  and  uncharitable 
words.  Everything,  as  saith  Solomon,  hath  his  time,  and 
truly  that  is  far  out  of  time,  yea  and  far  from  all  good 
honesty,  that  some  use  at  the  common  tables  and  without  any 


240  THE  "BYRTH  OF  MANKYNDE/' 

difference  before  all  companies,  rudely  and  loudly  to  talk  of 
such  tilings,  in  the  which  they  ought  rather  to  know  much  and 
say  little,  but  only  where  it  may  do  good,  magnifying  the 
mighty  God  of  nature  in  all  his  works,  compassionating  and 
pitying  our  even-Christians,1  the  women  which  sustain  and 
endure  for  the  time  so  great  dolor  and  pain  for  the  birth  of 
mankind  and  deliverance  of  the  same  into  the  world.  Praise 
God  in  all  His  works." 

The  rest  of  the  preliminary  matter  of  such  an  edition  as 
that  of  1560  consists  of  the  Table  of  Contents,  as  we  should 
now  call  it,  or,  as  it  is  here  termed,  simply  the  Table.  I  have 
collated  the  Contents  of  the  1545,  1552,  1560,  and  1654 
editions,  and  I  find  them  to  be  almost  identical,  except,  of 
course,  with  regard  to  the  spelling,  type,  and  pagination. 
There  are,  however,  one  or  two  small  divergences ;  thus,  in  the 
editions  of  1545  and  1654  there  is  a  heading  in  the  third  book 
("  Kemedy  for  the  Cramp,  or  distention  of  members  ")  which 
does  not  appear  in  the  other  two  editions  referred  to,  but  the 
presence  of  the  heading  does  not  indicate  the  addition  of  new 
matter  in  the  text;  again,  in  the  1545  and  1552 editions,  eleven 
Anatomical  Figures  are  named,  and  nine  only  in  the  1560  and 
1654  editions.  In  the  1560  edition  (in  my  copy  at  least)  the 
"  byrthe  fygures"  (seventeen  in  number  or  eighteen,  if  the 
"  stoole  "  be  counted)  follow  after  the  Table  of  Contents  ;  but  in 
several  of  the  other  editions  they  are  inserted  at  the  end  of  the 
fourth  chapter  of  the  Second  Book,  their  proper  place  according 
to  the  modern  rules  of  binding. 

Before  we  reach  the  Table  of  Contents  of  the  Jonas  edition 
of  1540,  we  find  additional  preliminary  matter  consisting  of  the 
Dedication.  It  is  so  interesting  that  I  reproduce  it  here  in 
full.  Some  parts  of  it,  it  may  be  added,  reappear  in  the 
Prologue  to  the  Women  Keaders  which  is  peculiar  to  the 
Kaynalde  editions.  In  ordinary  English  it  reads  as  follows : — 
1  Even-Christen  or  even-Christian  meant  fellow-Christian. 


BY   DR   J.    W.    BALLANTYNE.  241 

"Unto  the  Queen.  Unto  the  most  Gracious,  and  in  all 
goodness  most  excellent  virtuous  Lady  Queen  Katherine,  wife 
and  most  dearly  beloved  spouse  unto  the  most  mighty  sapient 
Christian  Prince  King  Henry  the  VIII.  Eichard  Jonas  wisheth 
perpetual  joy  and  felicity.  Whereas  of  late  (most  excellent 
and  virtuous  Queen)  many  goodly  and  proper  treatises,  as  well 
concerning  holy  scriptures,  wherein  is  contained  the  only 
comfort  and  consolation  of  all  godly  people  :  as  other  profane 
arts  and  sciences  right  necessary  to  be  known  and  had  in  use, 
have  been  by  the  painful  diligence  of  such  clerks  which  have 
embusied  them  in  the  same  very  earnestly  and  circumspectly 
set  forth  in  this  our  vulgar  English  tongue,  to  the  great 
enriching  of  our  mother  language,  and  also  the  great  utility  and 
profit  of  all  people  using  the  same,  and  among  all  other  things, 
out  of  the  noble  science  of  Physick,  have  been  divers  proper 
and  profitable  matters  compiled  and  translated  from  the  Latin 
tongue  into  English,  by  the  reading  of  the  which  right  many 
have  confessed  themselves  to  have  received  great  light  and 
knowledge  of  such  things,  in  the  which  they  have  found  no 
small  comfort  and  profit.  And  in  this  behalf  there  is  in  the 
Latin  speech  a  book  entitled  Be  Partu  Hominis :  that  is  to  say, 
of  the  birth  of  mankind,  compiled  by  a  famous  doctor  in 
Physick,  called  Eucharius,  the  which  he  wrote  in  his  own  mother 
tongue,  that  is,  being  a  German,  in  the  German  speech, 
afterward  by  another  honest  clerk  at  the  request  and  desire  of 
his  friend  transposed  into  Latin:  the  which  book  for  the 
singular  utility  and  profit  which  ensueth  unto  all  such  as  read 
it,  and  most  specially  unto  all  women  (for  whose  only  cause  it 
was  written)  hath  been  in  the  Dutch  and  French  speech  set 
forth  and  imprinted  in  great  number,  so  that  there  be  few 
matrons  and  women  in  those  parts  but  (if  they  can  read)  will 
have  this  book  always  in  readiness:  considering  then  that  the 
same  commodity  and  profit  which  they  in  their  regions  do  obtain 
by  enjoying  of  this  little  book  in  their  maternal  language,  might 

Q 


242  THE   "BYRTH   OF   MANKYNDE," 

also  ensue  unto  all  women  in  this  noble  realm  of  England,  I 
have  done  my  simple  endeavour  for  the  love  of  all  womanhood, 
and  chiefly  for  the  most  bound  service  which  I  owe  unto  your 
most  gracious  highness  to  translate  the  same  into  our  tongue. 
Most  humbly  desiring  first  your  grace's  highness,  and  then 
consequently  all  noble  ladies  and  gentlewomen  with  other 
honest  matrons  to  accept  my  pains  and  goodwill  employed  in 
the  same :  the  which  thing  as  I  do  not  doubt  for  the  wont 
and  incomparable  benignity  goodness  and  gentleness  inset  and 
planted  in  your  grace's  nature,  so  shall  it  be  no  little  encourag- 
ing unto  me  hereafter  with  farther  deliberation  and  pains  to 
revise  and  oversee  the  same  again,  and  with  much  more 
diligence  to  set  it  forth.  For  considering  the  manifold  daily 
and  imminent  dangers  and  perils,  the  which  all  manner  of 
women  or  what  estate  or  degree  they  be  in  their  labour  do 
sustain  and  abide :  yea  many  times  with  peril  of  their  life,  of 
the  which  there  be  so  many  examples  needless  here  to  be 
rehearsed.  I  thought  it  should  be  a  very  charitable  and  laud- 
able deed,  yea  and  thankfully  to  be  accepted  of  all  honourable 
and  honest  matrons  if  this  little  treatise  so  fruitful  and 
profitable  for  the  same  purpose  were  made  English,  so  that  by 
that  means  it  might  be  read  and  understanded  of  them  all,  for  as 
touching  midwives,  as  there  be  many  of  them  right  expert, 
diligent,  wise,  circumspect,  and  tender  about  such  business, 
so  there  be  again  many  more  full  undiscrete,  unreasonable  and 
far  to  seek  in  such  things  the  which  should  chiefly  help  and 
succour  the  good  women  in  their  most  painful  labour  .and 
throngs.  Through  whose  rudeness  and  rashness  only  I  doubt 
not,  that  a  great  number  are  cast  away  and  destroyed  (the  more 
pity).  For  this  cause  and  for  the  honour  of  Almighty  God,  and 
for  the  most  bound  service  the  which  I  owe  unto  your  grace, 
most  gracious  and  virtuous  queen,  I  have  judged  my  labour  and 
pains  in  this  behalf  right  well  bestowed,  requiring  all  other 
women  of  what  estate  soever  they  be,  which  shall  by  reading  of 


BY  DR   J.    W.    BALLANTYNE.  243 

the  same  find  light  and  comfort,  to  yield  and  render  thanks 
unto  your  most  gracious  highness,  wishing  greatly  that  it  might 
please  all  honest  and  motherly  midwives  diligently  to  read  and 
oversee  the  same,  of  the  which  although  there  he  many  which  do 
know  much  more  peradventure  than  is  here  expressed,  yet  am 
I  sure  in  the  reading  of  it  their  understanding  shall  be  much 
cleared  and  have  somewhat  farther  perseverance  in  the  same. 
It  is  no  small  charge  which  they  take  upon  them,  for  if  when 
any  strange  or  perilous  case  doth  chance,  the  midwife  be 
ignorant  or  to  seek  in  such  things  which  are  to  be  had  in  remem- 
brance in  that  case,  then  is  the  party  lost  and  utterly  perished, 
for  lack  of  due  knowledge  requisite  to  be  had  in  the  midwife. 
Wherefore  I  beseech  Almighty  God  that  this  my  simple 
industry  and  labour  may  be  through  your  grace  unto  the  utility, 
wealth,  and  profit  of  all  English  women,  according  to  my  utter 
and  hearty  desire  and  intent,  to  whom  also  I  daily  pray  long 
to  preserve  and  prosper  your  most  gracious  highness,  both  to 
the  continual  comfort  and  consolation  of  our  most  redoubted 
and  without  comparison  most  excellent  Christian  prince,  and 
also  the  joy  and  gladness  of  his  loving  subjects.     Amen." 

Of  course,  the  Table  of  Contents  of  the  1540  or  Jonas 
edition  differs  much  from  those  of  the  Eaynalde  editions  of  1545, 
1552,  1560,  etc.  There  is  no  reference  in  it  to  a  Prologue,  for 
no  such  thing  exists  in  the  1540  issue,  unless  we  regard  the 
Eeligious  Admonition  and  the  Dedication  as  jointly  constituting 
one.  Then,  we  note  the  absence  of  the  first  thirteen  chapters 
of  the  first  Book  of  all  the  Eaynalde  editions ;  and  the  sixth 
chapter  of  the  fourth  Book  of  the  Eaynalde  editions,  contain- 
ing the  cosmetic  suggestions  or  "bellifying  receipts/'  is  not 
represented  in  the  Table  of  Contents  of  the  1540  edition. 
Eoughly  speaking,  the  Jonas  or  1540  edition  contains  the  second, 
third  and  fourth  Books  of  the  Eaynalde  editions,  plus  the  last 
chapter  of  the  first  Book  and  minus  the  last  chapter  of  the  fourth 
Book  of  these  later  editions.    But  T  have  already,  in  my  former 


244  THE   "  BYRTH   OF   MANKYNDE," 

article,  set  forth  in  detail  the  differences  between  the  Contents 
of  the  two  issues  (loc  cit.,  p.  248). 

In  the  1540  edition  the  preliminary  matter  closes  with  two 
interesting  paragraphs  dealing  with  weights  and  measures  and 
with  drugs  and  apothecaries ;  they  are  peculiar  to  this  edition. 
The  former  is  introduced  in  these  words :  "  For  because  that  in 
this  book  many  times  be  found  certain  measures  and  weights  of 
physic,  not  known  peradventure  to  all  such  as  that  chance  to 
read  it,  therefore  here  briefly  I  have  set  them  forth,  showing 
the  value  and  estimation  of  them  so  far  as  they  shall  be 
requisite  to  the  better  understanding  of  such  things  the  which 
ye  shall  read  in  the  same  treatise."  Then  follows  the  table  of 
the  weights  and  measures,  the  pound  being  stated  to  contain 
5,762  grains.  The  second  paragraph  refers  to  the  obtaining  of 
the  drugs  named  in  the  text  of  the  book,  and  reads  thus :  "  Ye 
shall  also  note  here  that  many  times  ye  shall  happen  upon 
strange  names  of  such  things  the  which  are  occupied  about 
infirmities  spoken  of  in  this  book,  for  the  which  theyr  is  no 
English  but  are  used  in  their  own  proper  names  of  Greek  or 
Latin :  and  they  are  such  for  the  most  part  which  are  to  be  had 
only  at  the  apothecaries,  being  of  them  right  well  known ; 
wherefore  when  ye  shall  need  any  such  thing  if  ye  send  the 
same  names  in  your  bill  to  the  apothecaries  they  will  soon 
speed  your  purpose:  neither  do  this  if  ye  may  without  the 
advice  of  some  expert  and  learned  physitian." 

I  have  now  enumerated  all  the  parts  of  the  preliminary 
matter,  both  as  found  in  the  Eaynalde  editions  of  the  Byrth 
of  Manhynde  and  in  that  first  edition  with  which  the  name  of 
Eichard  Jonas  is  associated.  I  now  pass  to  the  Prologue, 
which  is  to  English  readers  perhaps  the  most  attractive  part 
of  the  work. 


DY   DR  J.    W.    BALLANTYNE.  245 


The  Prologue. 


To  the  English  obstetrician,  as  well  as  to  the  student  of  the 
manners  and  customs  of  the  sixteenth  century,  the  Prologue  to 
the  Women  Readers  will  be  by  far  the  most  interesting  part  of 
the  book.  It  is  not  a  translation  of  anything  in  Kosslin ; 1  it 
is  not  indeed  a  translation  of  anything  at  all.  We  may  regard 
it  as  a  piece  of  original  writing  fresh  from  the  mind  of 
Kaynalde,  giving  the  history  of  the  work  and  throwing  an 
important  sidelight  upon  the  way  in  which  obstetric  matters 
were  looked  upon  in  England  in  the  middle  of  the  sixteenth 
century.  There  are,  it  is  true,  a  few  passages  in  it  which  are 
reminiscent  of  some  parts  of  the  Dedication  to  Queen  Katherine 
in  the  1540  edition  ;  but  the  greater  part  of  it  must  be  ascribed 
to  Kaynalde. 

The  intent  of  the  author  ("  the  entent  of  thauctour ")  is  to 
recite  the  sum  and  chief  contents  of  the  book,  for  it  is  "  a  great 
pricke  or  allurement,  entising  and  meuinge  a  man,  to  reade  any 
boke,  when  he  is  somwhat  first  admonyshed  of  the  matters 
comprehended  and  contayned  therein."  Then,  without  giving 
any  names,  Kaynalde  tells  how  the  studious  and  diligent  clerk 
[Jonas,  to  wit]  made  the  English  translation  of  the  Latin  work 
[by  Kosslin]  entitled  Be  Partu  Hominis,  and  called  it  "the 
byrth  of  mankynde" ;  it  is  now  to  be  named  "the  womans 
boke."  That  translation  is  now  to  be  corrected  and  augmented, 
revised  "from  top  to  to,"  as  the  writer  quaintly  says;  and 
there  are  to  be  "  set  forth  and  evidently  declared  al  the  inward 
partes  of  women,  and  that  not  onely  in  wordes,  but  also  in 
lyvely  and  expresse  figures."  Kaynalde  beseeches  the  midwives 
who  will  read  his  book  to  pay  special  attention  to  these 
anatomical  matters,  for,  he  adds,  "  when  a  person  is  sycke  or 
dyseased  in  any  part,  it  is  halfe  a  comfort,  yea  halfe  his  helth, 

1  There  is  a  "  Prologue  "'  in  Rosslin's  De  Partu  Hominis  (edition  of 
1538,  Paris),  but  it  has  nothing  in  common  with  Raynalde's. 


246  THE   "BYRTH   OF  MANKYNDE," 

to  understand  in  what  part  the  dysease  is,  and  howe  that  parte 
lyeth  in  the  bodye." 

The  second  part  of  his  book  ("the  seconde  booke")  is  to 
concern  itself  with  labour,  "with  the  byrth  of  mankind  and 
al  the  daungers,  perels,  and  other  cases  happenyng  to  the 
labourynge  woman  at  that  season."  This  portion  of  the  work 
is  to  be  illustrated  with  the  Byrth  Fygures  and  the  picture  of 
the  Womans  Stoole ;  the  first  part  had  the  anatomical  figures 
from  Vesalius  to  elucidate  the  text. 

The  third  book  considers  the  choice  of  a  wet  nurse.  "  Item 
medicines  encreasyng,  deminishinge,  attenuatyng,  engrossinge, 
and  amendynge  the  mylke  in  the  nources  brestes.  Also 
remedies  for  manye  and  sundry  diseases,  which  oft  tymes 
chaunce  unto  infantes  after  theyr  byrth." 

In  the  fourth  book  the  author  proposes  to  discuss  the 
question  of  conception  and  the  overcoming  of  sterility.  "  And 
farther  in  this  last  booke  shall  be  uttered  and  set  forth  certayne 
embelleshinge  receptes  concerning  onely  honeste  and  helthsome 
decoration  and  clenlynes."  The  writer  evidently  feels  that  he 
is  on  dangerous  ground,  for  he  adds  that  he  is  to  teach 
"  nothinge  in  that  place  but  that  onely  whiche  may  make  to  the 
honest,  comely,  and  commendable  conservinge  and  maintaininge 
of  the  inset  and  natural  beautie  in  a  woman,  utterly  abhorring 
and  defying  all  farding,  paynting,  and  counterfeit  cast  coulors, 
which  of  some  dampnable  and  misproude  people  be  dayly  used, 
such  as  by  all  meanes  possible,  seke  and  search  more  the 
abhominable  and  divilish  painting  and  garish  setting  forth  of 
their  mortal  carcases  (the  better  therby  to  commend  it  unto  the 
eyes  of  foolish  and  fond  men)  than  by  honest,  sober,  debonayre 
and  gentil  maners,  so  to  demene  their  life,  that  they  may 
therby  rather  obtayne  the  loue,  amitie,  and  hartie  perpetual 
favour  first  of  god,  and  then  of  al  honest,  discrete,  and  godly 
wise  men." 

After  giving  this  brief  summary  of  the  contents  of  the  book, 


BY  DR  J.   W.   BALLANTYNE.  247 

Kaynalde  asks  his  women  readers  ("  for  whose  sake  and  only 
respect  it  is  set  forth ")  to  give  it  their  benevolent  favour  and 
good  acceptation.  He  is  quite  sure,  however,  that  to  some  the 
work  will  not  be  acceptable.  Not  even  an  invocation  of  the 
gods  and  goddesses  ("  great  Apollo,  wyttye  Mercury,  and  sweet 
Suada ")  will  suffice  to  convince  them  who  give  so  "  precipitat 
and  heady  judgementes  in  all  maner  of  matters,"  that  the  book 
is  useful  and  good.  Some  will  allege  "  that  it  is  a  shame,  and 
other  somme,  that  it  is  not  meete  ne  fyttynge  such  matters  to 
be  entreated  of  so  playnly  in  our  mother  and  vulgare  language, 
to  the  dyshonoure  (as  they  say)  of  womanhed,  and  the  derision 
of  theyr  wonte  secretes,  by  the  detection  and  disco verynge 
whereof,  men  it  readynge  or  hearing,  shalbe  moved  thereby 
the  more  to  abhorre  and  loo  the  the  company  of  women."  But 
it  is  of  no  use  to  attempt  to  convince  such  people.  Nothing 
is  so  good  but  it  may  be  abused.  Fire  and  water,  meat  and 
drink,  the  Bible,  even  the  blessed  Sacrament  may  be  abused; 
but  "  to  them  that  be  good  theimselfe,  everye  thinge  turneth  to 
good,  whatever  it  be  is  to  them  a  sufficient  matter  and  occasion 
therein  to  seke  the  glory  of  God,  and  the  onely  profyte  of 
their  even  Christen."  "  Wherefore,"  the  writer  concludes 
"  consydering  that  there  is  nothinge  in  this  world  so  necessary, 
ne  so  good,  holye,  or  virtuous,  but  that  it  maye  by  wyckednesse 
be  abused,  it  shalbe  no  great  wonder  though  this  lyttle  booke 
also,  made,  written,  and  set  foorth  for  a  good  purpose,  yet  by 
lyght  and  leude  persons  be  used  contrary  to  godlynesse,  honesty, 
or  thentent  of  the  wryter  thereof." 

The  only  possible  dangers,  so  far  as  the  writer  can  see,  are 
that  some  of  the  medicines  referred  to  may  be  employed  for  a 
criminal  purpose  ("some  divelishe  and  lewde  use"),  and  that 
the  book  falling  into  any  "  lyght  marchauntes  handes  "  may  be 
used  for  the  derision  of  women.  That  men  by  reading  such  a 
book  should  "  conceave  a  certayne  lothsomnes  and  abhorrynge 
towardes  a  woman,"  is  answered  by  the  fact  that  if  this  were 


248  THE   "BYKTH   OF   MANKYNDE," 

so  then  "  Physitians  and  chyrurgians  wyves  should  greatly  be 
abhorred  and  mysbeloved  of  theyr  husbandes  " ;  and  this  is  not 
so.  "And  I  my  self  likewise,  which  wryteth  thys  booke, 
should  mervaylouslye  above  many  other  abhorre  or  lothe 
women."  Such  "  tender  reasons  "  are  petty  and  trifling  ;  "  but 
to  be  short,  there  is  no  such  thyng,  neither  any  cause  thereto 
why."  In  fact,  it  is  rather  to  be  expected  that  if,  by  any 
chance,  a  husband  read  the  book,  he  may,  if  of  a  gentle  and 
loving  nature,  do  his  wife  good. 

Knowing  as  he  does  what  the  perils  of  childbirth  are,  the 
writer  thought  "  it  should  be  a  verye  charitable  and  laudable 
dede,  and  right  thankefully  to  be  accepted  of  al  honourable 
and  other  honest  matrones,  yf  by  my  paynes  this  lyttle  treatyse 
were  made  to  speake  Englyshe,  as  it  hath  been  longe  syth 
taught  to  speake  dutch,  frenche,  spanyshe,  and  dyvers  other 
languages."  The  Byrth  of  Manhyde  may,  if  properly  read  and 
consulted,  supply  the  "  roume  and  place  of  a  good  mydwife  " ; 
as  a  matter  of  fact,  the  writer  knows  that  it  has  been  so  used 
by  "  many  honourable  Ladies  and  other  worshipf ull  Gentle- 
women," and  with  much  profit.  But  again  it  has  to  be 
confessed  that  there  are  some  midwives  who  would  have  the 
book  forbidden,  "forsomuch  as  therein  was  descried  and  set 
foorth  the  secretes  and  privities  of  women,  and  that  every  boy 
and  knave  had  of  these  bookes,  reading  them  as  openly  as  the 
tales  of  Eobin  Hood,  etc."  "But  here  nowe  let  not  the 
good  midwives  be  offended  with  that,  that  is  spoken  of  the 
badde.  For  verely  there  is  no  science,  but  that  it  hath  his 
Apes,  Owles,  Bores,  and  Asses."  The  good  midwives,  however, 
were  glad  to  get  the  book.  "  And  thus  I  conclude  and  make 
an  ende  of  this  rude  Prologue,  requyryng  the  gentle  readers 
thereof,  that  yf  they  shall  fynde  anything  therein  in terpre table 
to  dyuers  senses,  to  accepte  onely  that  which  may  make  to  the 
best,  accordynge  to  my  meaning." 


BY   DR   J.    W.    BALLANTYNE.  249 


The  First  Book. 

Like  the  Prologue,  the  First  Book  of  the  Byrth  of  Mankynde 
contains  matter  which  is  not  to  be  found  in  Khodion's  De  Partu 
Hominis.  Its  contents  are  mainly  anatomical  descriptions. 
The  writer  is  very  sure  of  the  "  utilitie  of  the  first  boke  " ;  it  is 
"  as  a  key,  openyng  and  clearyng  the  matters  to  be  in  treated  of 
in  the  seconde."  It  deals  with  the  "fourme,  maner,  and 
situacion  of  the  inwarde  partes  of  a  woman/'  with  "the 
campe  or  fielde  of  mankynde  to  be  engendred  therein." 

An  interesting  paragraph  deals  with  the  relative  importance 
of  the  sexes  in  the  matter  of  procreation :  "  And  although  that 
man  be  as  principall  mouer  and  cause  of  the  generation :  yet 
(no  displeasure  to  men)  the  woman  doth  conferre  and  con- 
tribute much  more,  what  to  the  encreasement  of  the  child  in 
her  womb,  and  what  to  the  noryshment  thereof  after  the 
byrth,  then  doth  the  man.  And  doubtlesse  yf  a  man  woulde 
demaunde  to  whom  the  chylde  oweth  most  his  generation, 
ye  may  worthily  made  aunswere  that,  to  the  mother :  whether 
ye  regarde  the  paynes  in  bearynge,  other  els  the  conferrence  of 
most  matter  in  begettyng." 

The  organs  are  then  described  in  detail.  First,  "the 
principal  coates  of  the  body "  are  referred  to :  they  consist  of 
the  superficial  skin  or  cuticula,  of  the  "fleshye"  skin  or 
membrane  carnosa,  and  of  the  third  coat  or  adeps,  which  lies 
between  the  other  two.  "Immediately  under  the  fleshye  skin 
be  conteyned  the  Muskles."  Chapter  III.  of  the  First  Book  is 
specially  concerned  with  the  "  Muskles,"  and  particularly  with 
those  of  the  "  bellye."  These  are  the  musculi  obliqui  descen- 
dentes  or  "  the  Byaswyse  descendyng  muskles " ;  the  musculi 
obliqui  ascendentes  or  the  "  Byaswyse  ascending  muskles ; "  the 
musculi  recti  or  "  the  ryght  muskles  " ;  and  the  musculi  trans- 
versi  or  the  "  overthwart  muskles."     "  All  these  f oure  Muskles 


250  THE  "BYRTH  OF  MANKYNDE," 

be  to  the  entrayles  and  bowelles  within  the  belly,  as  foure 
seuerall  coates:  by  the  vertue  and  helpe  of  whom,  together 
with  the  ayde  of  the  midwiffe,  all  expulsion  both  upward  and 
downewarde  in  the  guttes,  in  the  stomacke,  in  the  matrix  of 
the  woman  in  the  tyme  of  labour,  and  also  in  the  bladder  in 
tyme  of  makyng  of  water,  is  wrought:  and  yet  besides  this 
utilitie,  they  clothe  (as  I  have  saide)  defende,  fortifie,  and 
strength  the  inwardes  of  the  belly." 

Chapter  IV.  of  the  First  Book  speaks  of  the  "  kell,  called 
Peritoneum,"  a  certain  "  thin  rime " :  it  "  yeldeth  unto  eche 
entrayle  a  coate  and  webbe  of  the  cloth  of  his  owne  body :  by 
the  whiche  his  livery,  they  be  the  more  arctly  and  straightly 
affixed  or  fastened  unto  hymselfe."  Chapter  V.  gives  the 
declaration  of  the  names  and  nature  of  the  Matrix.  "The 
Matrix,  the  Mother,  and  the  wombe,  do  signifie  but  one  thing, 
that  is  to  saye :  The  place  wherein  the  seede  of  man  is  con- 
ceaved,  fetified,  conserved,  nourished,  and  augmented,  unto  the 
tyme  of  deliuerance,  in  Latin  named  Uterus  and  Matrix." 
From  the  description  which  follows,  it  is  evident  that  the 
writer  intends  by  "Cervix  Uteri"  the  vulva  and  vagina. 
Chapter  VI.  deals  with  "  the  wombe  and  his  partes."  "  Nowe 
ye  shall  understande,  that  the  founde  or  bottome  of  the 
matrix  is  not  perfectly  round  bowlwyse,  but  rather  lyke  the 
forme  of  a  mans  heart,  as  it  is  paynted,  sauinge  that  the 
particion  or  clifte  in  the  matrix  betwene  both  corners,  the 
ryght  and  the  lefte,  is  not  so  profoundlye  dented  inwardes  as 
the  clyfte  in  the  hearte."  From  this  description  it  would 
almost  appear  as  if  the  uterus  of  one  of  the  Mammalia  were 
intended,  or  if  the  writer  had  come  across  a  case  of  minor 
malformation  of  the  organ  (uterus  septus)  in  the  human 
subject.  He  is  quite  sure,  however,  that  there  is  only  one 
"  holonesse "  in  the  womb ;  he  does  not  believe  in  the  seven 
"selles"  said  to  be  therein.  "In  tymes  passed,  dy verse 
Clarkes   haue    written,  and   many   other  haue   beleued,  that 


BY  DR  J.    W.    BALLANTYNE.  251 

there  shoulde  bee  seuen  selles,  or  seuen  distinct  places  in  the 
Matrix,  in  thre  of  the  whiche,  on  the  ryght  syde  shoulde  onely 
men  chyldren  be  conceyued,  and  in  the  other  three  on  the  lefte 
syde  women  chyldren,  and  yf  it  chaunced  that  the  seede  were 
conceaued  in  the  seuenth  sel,  whiche  was  the  myddelmoste, 
then  that  shoulde  become  a  monster,  halfe  a  man,  and  halfe  a 
woman.  The  whiche  all  is  but  lyse,  dreames,  and  fonde 
fantasyes :  for  the  womans  Matrix,  as  I  haue  saide,  is  euen  as 
a  stronge  bladder,  hauinge  in  it  but  one  uniuersall  holones, 
and  the  chylde  when  it  lyeth  in  it,  lyeth  euer  on  the  one  syde 
more  then  on  the  other,  the  head  beynge  towardes  one  of  the 
corners  or  angles,  and  not  upryghte  towarde  the  myddle 
brydge." 

Chapter  VI.  (VII.  correctly)  speaks  of  the  "  Mother  port." 
This  is  the  Cervix  as  we  nowadays  call  it.  "  It  is  of  the  forme 
of  a  haukes  bell,  or  other  lyttle  mores  belles"  (i.e.,  morris 
bells).  At  certain  times,  "the  Matrix  beynge  apte  and 
dysposed  thereto,  and  other  conditions  requisite,  thys  wombe 
porte  do  naturally  open  it  selfe,  attractinge,  drawing  and 
suckinge  into  the  wombe  the  sede  by  a  vehement  and  naturall 
desyre."  During  pregnancy  it  remains  closed,  "untyll  the 
tyme  of  delyueraunce,  at  what  tyme  agayne  it  delate th  and 
openeth  it  self,  in  such  amplytude  and  largenesse,  that  it  is 
wonderfull  to  speake  of." 

Chapter  VIII.  contains  a  description  of  the  vessels  of  seede, 
called  the  woman's  stones,  i.e.,  the  ovaries  as  we  now  know 
them,  "wherin  is  engendred  the  seede  and  sparme  that 
commeth  from  the  woman,  not  so  strong,  ferme,  and  myghtie 
in  operation  as  the  seede  of  man,  but  rather  weake,  fluy,  colde, 
and  moyste,  and  of  no  great  firmitie."  But,  the  writer  tells 
his  readers,  the  woman's  seed  is  just  as  proper  for  its  purpose 
as  the  man's.  "These  stones  be  nothynge  so  bygge  as  the 
stones  of  man,  but  lesse,  natter,  much  fashyoned  after  the 
shape  of  a  great  and  brode  almonde." 


252  THE  "BYRTH  OF  MANKYNDE," 

Chapter  IX.  has  to  do  with  the  "  sede  bringers,"  not,  let  it 
be  borne  in  mind,  the  Fallopian  tubes,  but  the  "  two  vaynes 
and  twoo  artyres  which  come  to  these  two  stones."  Here  we 
find  a  description  of  the  blood-vessels  of  the  pelvis  along  with 
the  views  then  held  as  to  the  origin  of  what  was  called  the 
"  woman's  seed,"  which  are  set  forth  at  length  in  Chapter  X. 
These  views  have  now  only  an  historical  interest,  for  the 
physiological  knowledge  on  which  they  rested  has  long  since 
been  replaced  by  more  correct  information.  To  the  curious, 
however,  the  description  given  of  the  four  "mines"  shops  or 
workhouses  existing  in  the  body  cannot  but  be  attractive. 
"  Of  this  sort  of  mines,  there  be  foure  principall  in  the  bod  ye 
of  man.  The  first  is  the  mine  of  bloud,  which  is  the  lyuer,  in 
whom  the  iuyce  of  meate,  before  of  colour  whyte,  is  transmuted 
into  red,  made  apt  and  fitte  to  nourishe  all  partes  of  the  body, 
attract  and  drawen  out  of  the  stomacke  and  guttes,  thorow 
verye  small  and  infinite  lyttle  vaynes  into  the  lyuer.  The 
seconde  mine  is  the  heart,  which  of  the  bloud  attracte  and 
drawen  from  the  great  maister  vaine,  proceading  out  of  the 
foresayde  lyuer,  into  his  parlers,  doth  engendre  vehement  and 
liuely  spirite,  conmixed  with  depured  and  greatly  elaborated 
bloud,  within  the  selles  of  the  heart,  from  thence  sent  forth 
throw  the  artires,  into  all  partes  of  the  bodye,  being  in  colour 
yealowyshe,  thinne,  and  hoote  bloud.  The  thyrde  mine  is  the 
brayne,  of  whom  all  the  sinewes  take  thyr  originall.  In  whom 
the  wyttye  spirite,  the  spirites  of  mouyng,  and  the  spirites  of 
al  sensibilitie  be  engendred,  and  thorow  the  sinewes  sent  to  all 
partes  of  the  bodye.  For  all  suche  partes  as  moue  and  feele, 
haue  that  by  reason  of  sinewes  derived  unto  those  places  from 
the  head.  The  fourth  mine  is  the  stones,  in  whom  by  commix- 
tion  of  al  the  other  thre  foresaid  metalles  of  the  body,  that 
is  to  say,  vayne  bloud,  arteriall  bloud,  and  liuely  spirites 
engendred  in  the  head,  is  engendred  and  produced  sede,  whioh 
bestowed  in  his  due  place  becommeth  like  in  perfection  to  the 


BY   DR   J.    W.    BALLANTYNE.  253 

creature  from  whence  it  came ;  that  is  to  say  of  mankynde, 
man."  The  writer  then  goes  on  to  explain  how  "  the  seede  is 
receaued  into  the  stones/'  how  the  colour  of  the  seed  is  trans- 
muted, and  how  the  seed  in  woman  is  not  so  firm  as  in 
man,  etc. 

Chapter  XL  tells  how  the  seed  (of  the  woman)  is  sent  from 
the  stones  to  the  angles  or  corners  of  the  Matrix  by  means  of 
a  "  wormye  bodye,"  evidently  the  Fallopian  tube.  The  seed  in 
woman  is  supposed  to  be  for  the  purpose  of  moistening  the 
genital  passage  as  "  with  a  dewe."  The  writer  then  proceeds 
to  moralize  on  what  he  terms  the  "  prickes  of  nature."  "  For 
yf  that  the  God  of  nature  had  not  instincted,  and  insette  in 
the  body  of  man  and  woman,  such  a  vehement  and  ardent 
appetite  and  luste,  the  one  lawfully  to  company  with  the 
other:  neither  man  ne  woman  woulde  neuer  haue  ben  so 
attentyfe  to  the  workes  of  generation  and  encreasement  of 
posteritie,  to  the  utter  decaye  in  shorte  tyme  of  all  mankynde. 
For  ye  shal  heare  some  women  in  tyme  of  theyr  trauayle, 
meued  through  great  payne  and  intollerable  anguyshe,  forswere 
and  vowe  them  selfe,  neuer  to  companye  with  a  man  agayne ; 
yet  after  that  the  panges  be  passed,  within  short  whyle,  for 
entyre  loue  to  theyr  husbandes,  and  singular  naturall  delyte 
betwene  man  and  woman,  they  forget  both  the  sorow  passed 
and  that  that  is  to  come.  Suche  be  the  privie  works  of  God, 
and  suche  be  the  prickes  of  nature,  which  neuer  createth  no 
special  pleasure  unaccompanyed  with  some  sorow:  neither  is 
there  for  the  most  part  any  sorow,  but  that  it  hath  annexed 
some  ioy  or  comforte,  lesse  or  more,  to  alleuiate  and  lyghten 
the  burthen  and  weyght  of  displeasure." 

Chapter  XII.  deals  with  the  bladder  in  women,  with  stone 
("  but  women  be  not  so  prone  ne  apt  to  engender  the  stone  in 
the  bladder  as  men  be "),  and  with  the  reason  why  the  urine 
when  it  has  reached  the  bladder  does  not  revert  again. 

Chapter  XIII.  is  a  very  interesting  one,  for  in  it  are  con- 


254  THE  "BYKTH  OF  MANKYNDE," 

sidered  not  only  the  "  vaynes  which  resort  to  the  Matrix/'  but 

also  "  the  termes  and  theyr  course  with  the  causes  thereof." 

"  Nowe  to  come  to  the  declaration  of  the  nature  of  termes,  ye 

shal   understand   that  thei  be  called  in  Latine  Menstrua,  for 

because  that  ons  in  a  moneth  they  happen  alwayes  to  woman- 

kynd,  after  XIII.  or  XV.  yeares  of  age  passed  (beynge  in  theyr 

perfect  health) :  In  Englyshe  they  bee  named  Termes,  because 

they  retourne  eftsoones  at  certayne  seasons,  tymes  and  termes." 

Having  described,  as  best  he  knew,  how  the  blood  was  poured 

into  the  Matrix,  the  writer  goes   on  to  tell  the  cause  of  the 

terms,  that  they  are  really  intended  to  serve  as  nourishment 

for    the   foetus   ("feature");   for  "prudent   Lady  nature"  has 

wisely   so   provided ;    "  yea,   although    the    woman    do   neuer 

conceaue  ....  yet   is   there   no   faute   in   nature,  who   hath 

prepared  place,  and  foode  to  be  at  al tymes  in  readynes."     It 

is   noted,  also,  that   women   that   have  no  terms  cannot  bear 

children ;  that  the  terms  do  not  follow  the  waxing  and  waning 

of  the  moon  exactly ;  and  that  the  duration  of  the  flow  varies 

in  different  women. 

In  Chapter  XIV.  are  considered  at  some  length  the  three 
cauls  or  wrappers  "wherein  the  infant  is  lapped"  in  the 
uterus.  The  innermost  caul  is  named  the  Amnios,  "  in  Latine 
Agnina,  for  cause  it  is  as  dilicate  as  lambes  bee."  "  The 
mydwifes  commonly  call  it  the  coyfe  or  byggyn  of  the  chylde, 
and  some  call  it  chyldes  shert,  the  which  also  many  times 
proceadeth  alone  with  the  chylde,  eyther  uppon  the  chyldes 
head,  or  one  of  the  armes  or  legges.  And  then  the  women 
reserve  it  as  a  thynge  that  shoulde  betoken  some  grat  lucke  to 
the  chylde  in  tyme  to  come."  "The  seconde  wrapper  or 
caule  in  Greek  is  called  Allantoides,  in  Latine  Farciminosa,  in 
Englyshe  these  two  termes  do  signifie  haggiswyse  for  because 
that  it  is  fashioned  much  after  the  shape  of  the  outwarde 
skynne  or  bagge  of  an  haggisse  puddinge."  This  second  caul  of 
Eaynalde  is  our  modern  chorion  apparently,  while  the  third 


BY  DR   J.    W.    BALLANTYNE.  255 

which  he  names  Chorion  or  Secundina  (or  hoop  caul)  would 
seem  to  correspond  to  the  placenta;  but  the  description  is 
vague  and  shows  no  evidence  of  close  observation  of  nature. 
The  description  of  the  vessels  of  the  umbilical  cord  is  more 
exact.  "  Thorow  these  Ar tires,  liuely  spirite  and  freshe  ayre 
is  deriued  out  of  the  mother  into  the  chylde,  wherwith  the 
naturall  heate  of  the  chylde  is  viuified  and  refreshed.  And 
these  two  Artires  with  the  foresayde  nauyll  Vayne,  when  the 
childe  is  borne,  begin  to  wyther  and  drye,  euery  day  more  and 
more,  and  become  much  like  a  harpstryng,  without  any  holow- 
nesse  or  cauitie."  The  urachus  ("another  vessell")  is  also 
described,  and  it  is  said  that  by  it  the  urine  passes  from  the 
bladder  to  the  space  between  the  first  and  second  caul  without 
the  child's  body.  The  placenta  ("  chorion  ")  is  compared  to  the 
spleen  or  melt  "  in  a  man  or  beast " ;  "  so  that  to  be  short, 
Chorion  is  the  immediat  receptacle  and  receauer  of  al  the 
vaynes  and  artires,  to  be  deduced  from  the  Matrix  to  the 
chylde,  and  the  chylde  recaueth  onely  at  his  hand  the  two 
Vaines  and  Artires,  whiche  by  the  way  as  they  passe  and  perse 
thorow  the  other  two  caules,  towardes  the  chyldes  Nauyll,  they 
sende  into  eche  of  the  caules  innumerable  small  eye  vaynes 
and  artires,  whereby  the  caules  be  sustayned  and  encreased 
also." 

The  terms,  when  there  is  a  foetus  in  the  uterus  to  be 
nourished,  are  no  longer  superfluous  but  are  used  in  supplying 
nourishment  to  the  infant  in  utero,  and  that  part  which  is  not 
needed  goes  to  the  breasts  to  become  milk.  It  is  not  right  to 
regard  the  terms  as  a  purgation,  for  the  blood  of  which  they 
are  composed  is  as  pure  and  wholesome  "  as  all  the  reste  of  the 
bloud  in  an  ye  part  of  the  body  els."  "  Yet  much  more  are  to 
be  detested  and  abhorred,  the  shameful  lyes  and  slaunder  that 
Plinie,  Albertus  magnus  de  secretes  Mulierum,  and  diuers  other 
mo  haue  written,  of  the  venimous  and  daungerous  infective 
nature  of  the  womans  Flowres  or  Termes :  the  which   all  be 


256  THE    "  BYRTH  OF   MANKYNDE," 

but  dreames  and  playne  dotage.  To  rehearse  theyr  fond  wordes 
here,  were  but  losse  of  inke  and  paper,  wherfore  let  them  passe 
with  theyr  auctours."  It  is  not  a  little  amusing  to  read  such 
denunciations  of  Pliny  and  Albertus  Magnus  following  so 
closely  after  some  of  the  anatomical  descriptions  that  have 
gone  before;  but  in  his  views  upon  the  functions  of  the 
placenta  as  set  forth  in  the  following  paragraph  the  writer 
is  far  in  advance  of  his  time.  "  Forbecause  that  she  (Nature) 
woulde  that  the  pure  bloud  commyng  from  the  Matrix  vaynes, 
should  be  made  yet  purer,  she  suffereth  not  the  same  to  entre 
immediately  into  the  infante,  but  first  useth  another  meane, 
and  sendeth  it  into  Chorion  or  the  hoope  call  (as  I  haue  sayd 
before),  where  truely  it  hath  a  certayne  circulation,  and  another 
digestion,  wherby  it  is  desecate,  and  clensed  very  exquisitly, 
by  the  diligentis  of  nature  attenuated  and  fined,  and  so  at  the 
laste  sent  foorth  into  the  infant,  leauyng  all  the  grosser  part 
in  the  spungye  bodye  of  the  hoope  caule."  (It  is  to  be  re- 
membered that  the  hoop-caul  is  the  placenta.) 

The  Fifteenth  Chapter  is  concerned  with  some  curious 
considerations  regarding  which  of  the  three  Matrix  veins 
contain  the  Terms  and  how  the  milk  comes  to  the  woman's 
breasts.  The  importance  of  knowing  which  of  the  veins 
contain  the  menses  is,  the  writer  thinks,  at  once  evident  when 
we  have  to  deal  with  too  much  or  too  little  monthly  flow ;  to 
put  these  anomalies  right  we  have  to  apply  medicines,  and  if 
the  menses  come  only  from  the  veins  of  the  neck  of  the  womb 
there  will  be  no  use  in  applying  medicines  to  those  of  the 
fundus.  The  writer  is  of  opinion  (for  reasons  which  it  is 
unnecessary  to  discuss  now)  that  the  terms  come  from  the 
veins  at  the  fundus  only.  It  is  in  this  connection  that  the 
writer  relates  the  history  of  two  cases  in  his  practice,  the  one 
in  London  and  the  other  in  Paris,  to  which  reference  has 
already  been  made  {Edin.  Obstet.  Trans.,  vol.  xxxi.,  p.  243, 
1905-06.) 


Fig.  1. 

Illustration  taken  from  Vesalius's  De  Hurnani  Corporis  Fabrica 
(Edition  of  1543),  where  it  is  the  Twenty-fifth  Figure  of  the 
Fifth  Book ;  it  appears  as  the  Second  Figure  in  the  Byrth 
of  Mankynde. 

[Between  pages  256  and  257. 


Fig.  2. 

Illustration  taken  from  Vesalius's  De  Hwmani  Corporis  Fabrica  (Edition  of  1642),  showing 
the  Nine  Figures  which  were  used  by  Raynalde  to  illustrate  the  Anatomical  Part  of 
the  Byrth  of  Mankynde. 


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Fig.  3. 

Figure  from  Vesalius's  De  Humani  Corporis  Fabrica  (Edition  of  1543),  representing  the 
Dissection  of  a  Man's  Body.  It  appears  as  Fig.  1  of  the  Anatomical  Figures  of  the 
1545  and  1552  Editions  of  Raynalde's  Byrlh  of  Mankynde,  but  is  omitted  from  that 
of  1560  and  from  all  subsequent  ones. 


Fig.  4. 


Figure  from  Vesalius's  De  Humani  Corporis  Fabrica  (Edition  of  1543), 
representing  the  Dissection  of  a  Man's  Body.  It  appears  as 
Fig.  2  of  the  Anatomical  Figures  of  the  1545  and  1552  Editions 
of  Raynalde's  Byrth  of  Mankynde,  but  is  omitted  from  all  the 
subsequent  ones. 


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Fig.  9. 


Figure  of  Twins  in  Utero,  from  Rhodion's  Be 
Partu  Hominis  (Edition  of  1538),  where  it 
appears  on  folio  29. 


Fig.  10. 


Figure  of  Double  Monster  in  Utero,  from  Rhodion's 
Be  Parlu  Jlominis  (Edition  of  1538),  where  it 
appears  on  folio  11. 


BY   DK   J.    W.    B ALLAN TYNE.  257 

There  is  much  else  in  this  chapter  about  clots  in  the  terms, 
about  the  "  white  flowers,"  about  retention  of  the  terms,  and 
about  the  manner  in  which  "  the  mylke  which  commeth  to  the 
brestes  is  engendred  of  the  Termes  (accordyng  to  moste  mens 
opinions)."  There  is  not  wanting  evidence,  it  is  pointed  out, 
of  the  "great  familiaritie  betwene  the  Matrix  and  the  brestes, 
for  so  much  as  the  ebbyng  of  the  one  is  the  flowinge  of  the 
other." 

Such  are  the  matters  dealt  with  in  the  First  Book  of  the 
Byrth  of  ManJcynde  in  the  1560  edition;  it  remains  for  me  now 
to  examine  the  differences  which  exist  between  this  and  other 
editions.  The  1545  and  1552  editions  call  for  no  special 
comment,  and  those  that  were  published  later  than  1560  also 
show  none  other  than  trifling  alterations;  but  the  Jonas  or 
1540  edition  differs  widely  from  the  rest. 

The  First  Book  of  the  1540  edition  is  really  the  Second 
Book  of  the  Kaynalde  editions  (with  some  exceptions  to  which 
reference  will  be  made),  and  the  First  Book  of  the  Eaynalde 
editions  finds  no  counterpart,  or  almost  none,  in  the  1540 
edition.  Almost  none,  for  the  First  Chapter  of  the  latter 
contains  an  account  of  "how  many  caules  the  birth  is 
compacted  and  wrapped  in,"  and  the  fourteenth  chapter  of  the 
Eaynalde  editions  deals  with  "the  three  caules  or  wrappers 
wherein  the  infant  is  lapped."  Chapters  I.  to  XIII,  Chapter 
XV.,  and  part  of  Chapter  XIV.  of  all  the  Eaynalde  editions 
find  no  counterpart  in  the  1540  edition  of  Jonas;  practically 
the  whole  of  the  First  Book  of  the  Eaynalde  editions,  therefore, 
is  new  material  added  to  what  was  in  the  1540  edition.  To 
trace  the  source  or  sources  of  the  new  material  found  in  all  the 
Eaynalde  editions  would  be  an  interesting  literary  investigation, 
but  it  is  one  which  I  am  not  now  in  a  position  to  make.  I 
may,  however,  state  that  no  part  of  the  added  chapters  is  in 
the  two  editions  of  Eosslin's  De  Partu  Hominis  which  I  have 
been  able  to  examine  (those  of  1538  and  1556);  and  in  the 

R 


258  THE   "BYRTH   OF   MANKYNDE,' 

meantime  it  is  only  reasonable  to  ascribe  it  to  Raynalde,  and 
to  regard  it  as  part  of  the  "  augmentation "  mentioned  on  the 
title  page  of  the  1545  and  subsequent  issues  of  the  Byrth  of 
Manhynde. 

The  Anatomical  Figures. 

At  the  end  of  the  First  Book  is  "  The  declaration  by  letters 
of  the  fygures  folowing,  wherein  be  set  forth  to  the  eye  euery 
parte  in  woman  mentioned  in  thys  boke  before:  Which  in 
the  former  Printinges  hath  ben  corrupted,  but  nowe  truely  set 
forth."  These  figures  are  nine  in  number,  and  they  have  all 
been  reproduced  in  Plates  IV.,  V.,  VI.,  and  VII.  of  my  former 
article. 

No  indication  is  given  in  the  letterpress  as  to  the  source  of 
the  illustrations ;  indeed  from  the  reading  of  the  accompanying 
descriptions  it  would  seem  that  they  were  original,  and  that 
the  objects  depicted  in  them  had  been  seen  by  the  writer.  A 
little  investigation,  however,  soon  shows  that  this  was  not  the 
case.  None  of  them  is  to  be  found  in  the  1538  edition  of 
Rosslin's  De  Partu  Hominis,  although  four  of  them  make  their 
appearance  in  the  1556  edition ;  but,  then,  as  we  shall  see,  they 
had  already  appeared  in  the  1545  edition  of  the  Byrth  of 
Manhynde  and  had  been  repeated  in  the  1552  edition.  Evidently, 
therefore,  their  original  source  is  not  Rosslin's  work.  As  a 
matter  of  fact,  they  have  been  taken,  description  and  all, 
from  Vesalius's  book  De  Humani  Corporis  Fabrica,  in  the 
"first"  or  1543  edition  of  which  they  are  all  to  be 
found. 

I  have  carefully  compared  the  plates  in  the  1560  edition  of 
Raynalde's  Byrth  of  Manhynde  with  those  in  the  1543  edition 
of  Vesalius's  work,  with  the  following  results : — The  first  figure 
in  Raynalde  is  the  twenty-fourth  of  the  Fifth  Book  of  Vesalius, 
and  is  found  on  p.  377  of  that  work,  with  the  descriptive  letter- 


BY  DR   J.    W.    BALLANTYNE.  259 

press  on  pp.  376,  377,  and  378 ;  the  second  figure  is  the  twenty- 
fifth  of  Vesalius,  and  is  found  on  p.  378,  with  its  description  on 
pp.  379  and  380 ;  the  third  figure  is  the  twenty-sixth  of  Vesalius 
on  p.  380;  the  fourth  figure  (IIII.)  is  also  to  be  found  in 
Vesalius's  work  at  the  end  of  his  Third  Book,  on  p.  313, 
with  its  description;  Figures  V.,  VI.,  VII.,  and  VIII.  of 
Eaynalde's  work  are  the  first,  second,  third,  and  fourth 
separate  figures  in  the  thirtieth  plate  of  Vesalius's  Fifth  Book, 
and  are  to  be  seen  on  p.  382,  with  descriptive  notes  on  p. 
383;  and  the  ninth  figure  of  Eaynalde's  Byrth  is  the 
twenty-seventh  of  the  Fifth  Book  of  Vesalius's  Be  Humani 
Corporis  Fabrica,  where  it  is  to  be  found  with  its  description 
on  p.  381. 

All  these  figures,  as  they  appear  in  the  1560  edition  of 
Eaynalde  have  been  reproduced  in  my  former  article,  where  they 
are  numbered  Figs.  IV.,  V.,  VI.,  and  VII.,  but,  in  order  to  pre- 
vent confusion,  their  proper  numbers  (I.,  II.,  III.,  IIII.,  V.,  VI., 
VII.,  VIII.,  and  IX.)  are  also  attached  to  them  (although  some 
of  them  were  reversed  in  the  original  printing,  e.g.,  IV.,  VII., 
and  IIIV.  for  VI.,  VII.,  and  VIII.).  In  order  that  the  reader 
may  compare  the  plates  as  they  appeared  in  Vesalius's  work 
with  their  reproductions  in  Eaynalde's  1560  edition  of  the 
Byrth,  I  give  here  Vesalius's  twenty-fifth  figure  corresponding 
to  Eaynalde  s  Fig.  II.  (Fig  I.) :  it  can  be  studied  alongside  of 
the  Eaynalde  reproduction  (Fig.  V.  of  my  former  article). 
Further,  in  a  later  edition  of  Vesalius's  work  (that  of  1642) 
all  the  nine  figures  used  by  Eaynalde  were  grouped 
together  in  one  plate  (on  p.  96),  and  I  have  thought  it 
worth  while  to  reproduce  this  also  (Fig.  II.).  It  represents 
in  graphic  form  Eaynalde's  unacknowledged  indebtedness  to 
Vesalius. 

The  descriptions  of  the  figures  are  literal  translations  of  the 
Latin  text  which  accompanied  the  illustrations  in  Vesalius's  Be 
Humani  Corporis  Fabrica.     I   give  here   in   parallel   columns 


260 


THE   "BYRTH   OF   MANKYNDE,' 


the  Latin  description  of  Figure  II.  and  the  English  translation 
of  it:— 


A  praesentis  figurae  dextra 
mamilla  cutem  abstulimus,  ut 
quam  fieri  posset  proxime  mamil- 
larum  natura  hie  oculis  subji- 
ceretur.  Deinde  ventriculum,  et 
cum  intestinis  mesenteriuin  et 
lienum  resecuimus,  recto  interim 
intestino  non  secus  quam  in  mox 
praecedente  figura  relicto.  Ad 
haec,  uterum  suo  extimo  quod 
peritoneum  ipse  porrigit  involucro 
quodammodo  spoliavimus,  omnes 
membranas  quam  licuit  accura- 
tissime  passim,  ideo  amputantes, 
ut  seminis  materiam  testibus 
def erentia  et  rursus  semen  ab  his 
utero  deducentia  vasa  in  con- 
spectum  venirent.  Vesicam  vero 
deorsum  in  sinistrum  latus  reflexi- 
mus,  una  meatum  a  dextro  rene 
ipsi  urinam  deferentem  abrum- 
pentes,  ut  urinam  vesicae  depren 
tium  meatuum  insertio  appareret, 
ipsaque  vesica  uteri  inspectionem 
non  occuparet.  Postremo  pubis 
ossium  portionem  ab  hac  figura 
exsecuimus,  quo  uteri  cervix  ac 
vesicae  etiam  collum  apposite 
viderentur. 


We  have  here  taken  away  the 
skyn  from  the  ryght  teate  of  this 
present  figure,  that  the  nature  of 
the  teates  mighte  as  nygh  as  may 
be,  be  set  before  the  eyes,  and 
afterwards  we  have  cut  awaye 
the  ventricle  with  the  bowels,  and 
also  Mesenterium  and  the  splene, 
leaving  the  strayte  entrayle  in 
thys  place  unmedled  with,  as  well 
as  we  dyd  in  the  fygure  before. 
And  moreover,  we  have  as  it  were 
taken  awaye  from  the  uttermooste 
cote  which  Peritonium  gave  unto 
it,  cutting  away  also  al  the  pan- 
nicies,  that  the  vessels  caryinge 
forth  the  substaunce  and  matter  of 
sede  to  the  stones,  and  also  the 
vessels  carying  away  the  sede 
from  thence  to  the  Matrix  shoulde 
appeare-and  bee  seene.  Also  we 
have  tourned  over  the  bladder 
downewarde  on  the  lefte  syde, 
lykewyse  breaking  the  way  or 
conduite  which  beareth  foorth 
the  urine  to  it  from  the  ryght 
kydneye,  that  the  insertion  of  the 
wayes  of  bearyng  forth  the  urine 
to  the  bladder  myght  appeare,  and 
that  the  bladder  shuld  not  let  the 
inspection  or  sight  of  the  Matrix 
or  Wombe.  Last  of  all  we  have 
cutte  away  from  this  fygure  a 
portion  of  the  bones  above  the 
privie  membres,  thot  the  neckes  of 
the  matrix  and  of  the  bladder  might 
the  more  commodiously  be  sene. 


BY  DR  J.   W.    BALL  ANT  YNE.  261 

The  comparison  of  the  Latin  description  with  the  English 
translation  leaves  no  donbt  that  Raynalde  boldly  appropriated 
both  the  plates  and  their  accompanying  text  from  the  work  of 
Vesalius ;  he  was  not  even  at  the  trouble  of  altering  personal 
details  which  referred  to  Vesalius,  such  as  the  allusion  to  his 
work  at  the  University  of  Padua  which  occurs  in  the  explana- 
tion of  the  ninth  figure.  In  this  respect,  however,  he  did  not 
differ  from  the  editor  of  some  of  the  later  editions  of  Rhodion's 
Be  Partu  Hominis  {e.g.,  that  of  1556),  who  also  borrowed  some 
of  Vesalius's  plates  without  acknowledgment. 

What  has  been  said  above  refers  to  the  1560  edition  of 
Raynalde's  Byrth  of  Mankynde.  When  we  turn  now  to  the 
1545  and  1552  editions  we  find  two  other  anatomical  figures 
(making  eleven  in  all),  named  the  fyrst  and  second  fygures, 
along  with  several  differences  in  the  accompanying  descriptive 
letterpress.  The  wording  of  the  Declaration  differs  slightly, 
the  reference  to  corruptions  in  the  printing  not  appearing.  It 
reads:  "The  declaration  by  letters  of  the  fygures  folowyng, 
wherein  be  set  forth  to  the  eye  every  part  in  woman  mencioned 
in  thys  Boke  before."  The  first  and  second  figures,  however, 
represent  dissections  of  a  man's  body,  and  at  the  end  of  the 
descriptive  letterpress  the  editor  somewhat  ingenuously  says : 
"  Here  ye  shal  be  advertysed  that  although  these  ii  fyrst  fygures 
be  made  principally  for  ye  man,  yet  may  they  serve  as  wel 
to  expresse  the  woman :  for  the  man  and  woman  differ  in 
nothyng  but  in  the  pryvie  partes."  These  two  illustrations  also 
are  borrowed  from  Vesalius's  Be  Humani  Corporis  Fabrica, 
where  they  appear  on  pp.  355  and  356  of  the  1543  edition,  and 
are  named  the  first  and  second  figures  of  the  Fifth  Book.  They 
are  reproduced  here  as  Plates  III.  and  IV.  I  place,  again  in 
parallel  columns,  the  Latin  and  the  English,  and  it  will  be  noted 
that  the  latter  is  not  so  strictly  a  translation  of  the  former  as 
in  the  descriptions  of  the  1560  edition : — 

Praesenti  figura  tanta   humani         In  the  fyrst  fygure  is  set  forth 


262 


THE  "BYRTH  OF  MANKYNDE. 


corporis  portio  delineatur,  quanta 
ad  peritonaei  sedes  ostendendas 
sufficit :  exprimitur  itaque  hac 
figura  anterior  peritonaei  sedes, 
sectionis  serie  ab  octo  abdominis 
musculis  libera,  nullaque  ex  parte 
dissecta. 

A,A,B,C,D.  His  characteribus 
peritonaeum  insignitur,  quodamo- 
doque  hac  figura  terminatur. 

E,E.  Linea  a  mucronata  pecto- 
ris ossis  cartilagine  ad  pubis  usque 
ossium  commissuram  procedens, 
cui  oblique  descendentium  et  as- 
cendentium,  et  transversim  pro- 
cedentium  abdominis  musculorum 
nervosae  tenuitates  pertinacissime 
connas-cuntur. 

F.  Umbilicus,  quern  inter  dis- 
secandum  etiam  adeptis  abdominis 
musculis,  gratia  opportunae  um- 
bilici vasorum  demonstrationis, 
reservare  solemus. 

G.  Seminaria  sinistri  later  is 
vasa  suis  membranis,  quas  a  peri- 
tonaeo  mutuantur,  adhuc  obvoluta. 

H.  Seminaria  dextri  lateris 
vasa. 

I.  Vena  ac  arteria  quae  potis- 
simum  inferiori  sedi  rectorum 
abdominis  musculorum  exporri- 
guntur,  quorum  et  hie  quoque 
l>ropendet  portio. 

K.  Vena  et  arteria,  quae  sub 
osse  pectoris  exporrectae,  in  an- 
teriorem  abdominis  sedem  prola- 
buntur,  praecipue  rectis  abdominis 
oblatae  musculis,  ac  superiore  ab- 
dominis sedem  universam  quoque 
implicates :    quemadmodum    illae 


so  moch  of  a  man's  body  as  may 
be  sufficient  to  show  the  forme 
of  thee  kell  called  Peritoneum : 
spoken  of  in  the  iiii  Chapter, 
Whose  compasse  is  here  noted 
wyth  A,B,C,D. 

A,A.  Noteth  the  grystell,  nether 
ende  or  poynt  of  the  brest  plate, 
in  the  pyt  or  pitch  of  the  brest 
agaynst  the  stomacke. 

E,E.  is  a  lyne  descendyng  upon 
Peritoneum  from  the  sayde  grystle, 
downe  to  the  myddle  joynt  of  the 
share  bone. 

F.  is  the  navell. 

G.  sygnifieth  the  sede  vessels  of 
the  lefte  syde  in  men  descendynge 
out  of  the  amplytude  of  the 
bellye. 

H.  is  the  ryght  seede  vessell : 
but  thys  G.  and  H.  hath  no  place 
in  the  women. 

I.  sygnyfieth  the  ascendinge 
vayne  and  arty  re  mencyoned  in  the 
last  chap. 

K.  the  descending  brest  vaynes 
and  artyres  spoken  of  in  the  same 
Chapt.  as  for  other  letters  that  be 
in  this  figure  I  wyl  make  no 
further  declaration  of  them,  for 
because  they  serve  nothing  to  this 
present  purpose. 


BY  DR   J.    W.    BALLANTYNE.  263 

quas    insignivimus,   humiliore    et 
pubis  ossibus  viciniore  implicat. 

L.  Venarum  soboles  in  peri- 
tonaei  latera  excurrentium,  ac  ab 
illis  venis  deductarum,  quae  aut  a 
conjuge  carente  vena,  aut  geni- 
culatim  a  cava  pronascuntur,  qua 
ipsius  caudex  lumborum  vertebris 
colugatur,  etc. 

Other  differences  between  the  edition  of  1560  and  those  of 
1545  and  1552  remain  to  be  noted.  These  consist  chiefly  of 
verbal  differences  in  the  descriptions  of  the  figures.  Figures  3, 
4,  5,  6,  7,  S,  9,  10,  and  11  of  the  earlier  editions  correspond  to 
Figures  1,  2,  9,  3,  4,  5,  6,  7,  and  8  of  the  1560  edition.  To 
show  the  extent  of  the  verbal  changes  I  place  here  in  parallel 
columns  the  description  of  the  fifth  figure  of  the  1552  edition 
and  the  ninth  figure  of  the  1560  edition;  they  represent  the 
same  specimen,  but,  as  will  be  seen,  differ  considerably : — 

1552  Edition.  1560  Edition. 

This  5  fygure  is  pourtrayed  after  And  the  nynth  figure  sheweth 

ye  quycke,  bothe  in  length  and  the  Matrix  cut  forth  of  the  body, 

bredtli,  according  to   the   length  being  of  that  bygnesse  as  it  was 

and   bredth   of   the  matrix  of  a  sene  taken  foorth  of  a  woman  at 

woman  which  was  cut  open  for  the  the  laste  Anothomye,  which  I  dyd 

same  purpose  by  phisitions.    But  se  at  the  universitie  of  Padua  in 

ye  must  understand  that  here  ye  Italy.    And  moreover  we  haue  so 

founde  or  body  of  ye  wombe  or  devyded  and  cutte  a  sunder  the 

matrix  is  devyded  in  ye  myddes  :  bottome    of    the    Matrix  by  the 

the  forepart  of  the  which,  is  turned  myddle,  that  the  concavitie  and 

up,  for  because  that  ye  maye  the  hollowe  bought  within  the  same 

better  perceave  ye   cavite   of  the  myght  be  perceaved,  and  the  thicke 

matrix  signed,  the  uppermost  with  substaunce  also  of  both  the  coates 

A.A.C.      The    nethermoste    halfe  of  the   Matrix  in   women,  when 

wyth    B.B.D.    Item.    C.    in    the  they  be  not  with  chylde. 

uppermost  halfe  and  D.    in   the  A.A.B.B.      The  concavitie  and 

nethermost  halfe  show  the  seame  holowe  bought  of  the  bottome  of 

or  lyne  spoken  of  cap.  vi.    E.E.  the  Matrix. 


264 


THE   "BYRTH   OF   MANKYNDE, 


both  in  the  upper  and  also  in  the 
nether  betoken  ye  crassenes  or 
thickenesse  of  ye  inner  coate,  wall 
or  skyn  of  the  matrix  in  wemen 
not  beinge  with  chyld,  through 
the  contraction  thereof  as  ye  shall 
farther  rede  in  the  sayd.  vi  chapt. 
F.F.  the  propendynge  or  heldynge 
parte  of  the  seme  in  the  matrix 
spoken  of.  cha.  vi.  G.G.  is  the 
porte,  oryfyce,  or  gate  of  the 
wombe.  H.H.  is  the  second  and 
utter  coate  of  the  matrix  geven  to 
it  from  Peritoneum.  I.I.  on  both 
sydes  of  the  necke  of  the  matrix, 
do  sygnifie,  part  of  the  kel  called 
Peritoneum,  sticking  yet  to  the 
sydes  of  the  Matrix  and  the 
necke  thereof.  K.K.  is  the  place 
where  the  matrix  is  fastened  to 
the  upper  part  of  the  privy 
passage,  ca.  vii.  L.  signifieth 
the  stub  of  ye  bladders  necke, 
wher  it  entreth  into  ye  forepart  of 
ye  privy  passage. 


CD.  A  line  somewhat  after 
the  maner  of  a  seame  called  in 
Latin  Scortum,  which  doeth  be- 
longe  to  the  place  wherein  the 
testycle  doo  lye,  whiche  swelleth 
somewhat  foorth  into  the  bought 
of  the  bottome  of  the  Matrix. 

E.E.  The  thickness  of  the  inner 
and  proper  coate  of  the  bottome 
of  the  matrix. 

F.F.  A  portion  of  the  inner- 
more  bottome  of  the  Matrix,  swell- 
yng  foorth  downeward  from  the 
hygher  seate  of  the  Matrix,  into 
the  holownes  and  bought  of  the 
bottome. 

G.G.  The  beginning  of  the 
necke  or  the  opening  place  of  the 
bottome  of  the  Matrix. 

H.H.  The  seconde  or  uttermore 
infolder  of  the  bottome  of  the 
Matrix,  descended  from  Peri- 
toneum. 

I.I.  Here  we  have  reserved  a 
portion  on  bothe  the  sydes  of  the 
thinne  coverynges,  descended  from 
Peritonium,  and  conteynyng  the 
Matrix. 

K.  Here  is  also  sene  the  sub- 
staunce  of  the  necke  of  the  Matrix, 
because  the  cuttyng  wherewith  we 
devyded  the  bottome  of  the  Matrix, 
was  begunne  at  this  place. 

L.  A  part  of  the  necke  of  the 
bladder,  implanted  into  the  necke 
of  the  Matrix,  castynge  foorth  into 
it  the  urine.  The  swellyng  partes 
of  Abdomen  and  whatsoever  is  els 
to  be  considered  thereof,  they  may 
be  sufficiently  knowen  without 
derection  of  Karacters. 


BY  DR  J.   W.   BALLANTYNE.  265 

On  comparing  these  two  descriptions  with  the  original 
Latin  inscription  found  in  Vesalius's  work,  I  find  that  the  first 
is  a  free  and  the  second  a  literal  translation  thereof.  In  the 
first  (that  of  1552)  all  mention  of  Padua  is  omitted,  while  in 
the  second  (that  of  1560)  it  is  referred  to,  with  the  addition  of 
the  words  "University  of"  and  "in  Italy,"  which  are  not  in 
Yesalius's  text.  On  the  whole,  we  must  accept  as  substantially 
correct  the  statement  made  in  the  1560  edition,  that  "the 
declaration  of  the  fygures  ...  in  the  former  Printinges  hath 
ben  corrupted,  but  is  nowe  truely  set  forth,"  if  by  that  is 
meant  a  closer  adherence  to  the  text  of  Yesalius's  work. 

The  Jonas  edition  of  1540  is  supplied  with  no  anatomical 
figures. 

The  Second  Book. 

The  contents  of  the  Second  Book  (of  all  editions  subsequent 
to  that  of  1540)  are  of  less  interest  to  English  obstetricians,  for 
they  are  simply  a  translation,  rather  free  perhaps,  of  Ehodion's 
book  Be  Partu  Hominis.  I  shall  first  enumerate  the  subjects 
dealt  with  in  this  Book,  taking  again  the  edition  of  1560  as  the 
standard  Eaynalde  one,  and  I  shall  then  compare  the  matter  as  it 
appears  in  the  various  editions,  and  consider  the  character  of  the 
translations  with  which  Jonas  and  Eaynalde  have  furnished  us. 

The  first  chapter  of  the  Second  Book  of  the  1560  edition 
(and  of  all  the  others,  except  that  of  1540)  corresponds  to  the 
second  chapter  of  the  work  of  Ehodion  (which  is  not  divided 
into  "  Books,"  but  simply  into  twelve  chapters). 

Chapter  I.  begins  with  a  short  paragraph  summarizing  the 
contents  of  the  First  Book,  and  then  proceeds  to  deal  with  "  the 
tyme  of  byrth,  and  which  is  called  naturall  or  unnaturall."  The 
premonitory  signs  of  labour  are  named :  "  first  certaine  dolours 
and  paines  begin  to  growe  about  the  guttes,  the  Navyll,  and  in 
the  raynes  of  the  backe,  and  lykewyse  about  the  thyghes,  and 
the  other  places  beynge  neare  to  the  privie  partes,  which  lyko- 


\ 


266  THE  "BYRTH  OF  MANKYNDE," 

wise  then  beginneth  to  swell  and  to  burne,  and  to  expell 
humours,  so  that  it  geveth  a  plaine  and  evident  token  that  the 
labour  is  nere."  Then  comes  a  definition,  which  at  least  does 
not  err  by  entering  too  much  into  detail :  "  Naturall  byrth  is 
when  thy  chylde  is  borne  both  in  due  season  and  also  in  due 
fashion."  The  due  season  is  "  most  commonly  after  the  ninth 
moneth,  or  about  fortie  wekes  after  the  conception  " ;  and  then 
follows  that  oft-repeated  and  widely-believed  statement  about 
the  poor  chances  of  survival  which  an  eighth  month  child  has 
as  compared  with  one  born  at  the  seventh  month  (when  "  the 
chylde  proveth  very  well ").  The  writer  is  somewhat  in  error 
when  he  describes  the  "  due  fashion " :  "  first  the  heade 
commeth  forwarde,  then  foloweth  the  necke  and  shoulders,  the 
armes  with  the  handes  lying  close  to  the  body  towardes  the 
face  and  forepart  of  the  chylde,  beyng  towardes  the  face  and 
forepart  of  the  mother,  as  it  appeareth  in  the  first  of  the  byrth 
figures."  This  definition  makes,  therefore,  a  face  to  pubes  case 
the  natural  one,  which  is,  of  course,  an  error.  The  author 
(Rhodion)  is  on  safer  ground  when  he  states  that  "  yf  the  byrth 
be  naturall,  the  dely  veraunce  is  easy  without  longe  tarying  or 
lokynge  for  it."  The  "  byrth  not  natural  is,  when  the  mother  is 
delyvered  before  her  tyme,  or  out  of  due  season,  or  after  anye 
other  fashion  then  is  here  spoken  of  before :  As  when  both  the 
legges  proceade  fyrst,  or  one  alone,  with  both  the  handes  up,  or 
both  down,  other  els  the  one  up  and  the  other  downe,  and 
dyvers  otherwyse,  as  shalbe  hereafter  more  clerely  declared." 
The  "other  els"  as  stated  in  the  next  chapter  is  "  sidelonge 
(the  which  is  most  perellous)  or  arselonge,  or  backlonge,  other 
elles  (havinge  two  at  a  byrth)  both  proceade  with  their  feet 
fyrste,"  etc. 

Chapter  II.  deals  with  "easy  and  uneasy,  difficult,  or 
dolourous  deliveraunce,  and  the  causes  of  it :  with  the  signes 
howe  to  knowe  and  foresee  the  same."  "  Verye  manye,"  says 
the  writer,  "bee  the   perylles,  daungers   and    thronges,  which 


BY  DR   J.   W.    BALLANTYNE.  267 

chaunce  to  women  in  theyr  labour,  which  also  ensue  and  come 
in  dyvers  waves,  and  for  dyvers  causes,  such  as  I  shall  here 
declare."     Among  the  causes  of  delay  in  labour  several  are 
enumerated  which  are   nowadays  little   accounted   of  or   not 
considered  at   all,   while    others   are   omitted    which    are   of 
importance.     Few,  for  instance,  will  agree  with  the  statement 
that  the  "  byrth  of  the  man  is  generally  easier  then  the  byrth 
of  the  female."     Some  of  the  causes  are  curiously  set  forth, 
such  as,  if  the  mother  be  "  too  spare  or  leane,  or  that  she  never 
had  chylde  before,  or  that  she  be  over  timorious  and  fearefull, 
dyvers,  waywarde,  or  such  one  that  wyll  not  be  ruled,  removy- 
ing  her  selfe  from  one  place  to  another."     The  old  belief  in 
the   birth   of   the   child  by  its  own  efforts   appears   in  such 
statements  as :  "  yf  the  childe  be  so  faynt,  weake  and  tender, 
that  it  cannot  tourne  it  selfe  or  doth  it  very  slowly ; "  "  also  if 
the  childe  be  dead  in  the  mothers  belly,  it  is  a  very  perellous 
thing,  for  so  much  as  it  cannot  be  easely  turned,  neither  can  it 
welde  or  helpe  it  self  to  come  forth,  or  if  the  chyld  be  sicke  or 
weakned  so  that  it  cannot  for  feblenes  helpe  it  self."     Then, 
various  signs  are  enumerated  to  help  the  midwife  to  tell  in 
what  cases  the  unborn  infant  is  weak  or  sick,  such  as  if  the 
pregnant  woman  has  been  "  sore   lasked," *  if  she   have  had 
"  dayly  and  unwontly  her  flowres,"  if  "  strayght  after  one  moneth 
upon  the  conceptyon  her  brestes  yelde  any  milke."     Causes  of 
delay  due  to  teratological  states  were  not  unknown  to  the  writer, 
for  he  says  that  there  will  be  difficulty  if  that  with  which  the 
woman  laboureth  "  be  a  monster,  as  for  example,  yf  it  hath  but 
one   bodye   and   two    heades,   as   appereth   in   the   XVII.    of 
the  birth  figures  such  as  of  late  was  sene  in  the  dominion  of 
Werdenbergh." 2      Faults  in  the  "secondine  or  latter  birth" 

1  Lasked,  purged. 

2  Werdenbergh,  a  town  in  Switzerland  on  the  Rhine,  in  the  Canton 
of  St  Gall.  The  monstrosity  referred  to  appears  as  fig.  x.,  near  the  end 
of  this  article. 


268  THE    "BYKTH   OF  MAKKYKDE," 

(membranes),  such  as  firmness  or  slenderness  are  also  named, 
and  the  delay  due  to  loss  of  humidities  from  early  rupture  is 
referred  to.  "And  farther  if  the  woman  have  used  to  eate 
commonly  suche  meate  or  fruytes,  which  do  exiccate  or  drye, 
and  constrayne  or  bynde,  as  Medlars,  Chestenuts,  and  al  sowre 
fruites,  as  Crabbes,  Chokeperes,1  Quinces  and  suche  other,  with 
over  muche  use  of  Vergeus,2  and  such  lyke  sowre  sauces,  with 
Eise,  Mill,3  and  many  other  thynges,  all  thys  shall  greatly  hynder 
the  byrth."  "  Also,"  the  writer  continues,  "  the  use  of  colde 
bathes  after  the  fyrst  moneth  folowing  the  conception,  or  to 
bathe  in  such  water  where  Alome  is,  Iron,  or  Salt,  or  anye 
suche  thynges  whiche  do  coarcte  and  constrayne,  or  yf  she  have 
bene  often  tymes  heavye  and  mourninge,  or  ill  at  ease,  or  yf  she 
have  bene  kepte  over  hungry  and  thursty,  or  have  used  over 
much  watche  and  walkinge,  eyther  yf  she  used  a  lyttle  before 
her  labour  things  of  great  odour,  smel,  or  savour,  for  suche 
thynges  (in  manye  mens  opinions)  attract  and  drawe  upward 
the  Mother  or  Matrix ;  the  which  is  great  hinderaunce  to  the 
byrth." 

The  chapter  closes  with  an  enumeration  of  the  tokens  of  an 
easy  labour.  "Nowe  sygnes  and  tokens  of  an  expedite  and 
easie  delyveraunce,  be  suche  as  be  contrarye  to  all  those  that 
have  ben  rehearsed  before.  As  for  example,  when  the  woman 
hath  bene  wonte  in  tymes  passed,  easely  to  be  delyvered,  and 
that  in  her  labour  she  feele  but  little  thronge  or  dolour,  or 
though  she  have  great  paynes,  yet  they  remayne  not  still  in  the 
upper  partes,  but  descend  alwaies  downewardes  to  the  nether 
partes  or  bottome  of  the  belly.  And  to  be  short,  in  all  payne- 
full  and  troublesome  labours  these  signes  betoken  and  signifie 
good  spede  and  lucke  in  the  labour :  unquietnes,  much  styringe 

1  Choke-pear,  any  "rough,  harsh,  and  unpalatable  variety  of  the 
pear,  used  for  perry,"  a  sort  of  crab-pear. 

2  Vergeus,  or  verjuice,  a  liquor  expressed  from  crab-apple,  sour  grapes, 
etc. 

3  Mill,  millet. 


BY  DR  J.    W.    BALLANTYNE.  269 

of  the  chylde  in  the  Mothers  bellye,  all  the  thronges  and 
paynes  tomblynge  in  the  forepart  of  the  bottome  of  the 
belly,  the  woman  stronge  and  mightie  of  nature,  such  as  can 
wel  and  strongly  helpe  her  self  to  the  deliveraunce  of  the  byrth. 
And  agayne,  evyl  signes  be  those,  when  she  sweteth  colde 
sweate,  and  that  her  pulces  beate  and  labour  over  sore,  and  that 
she  her  self  in  the  labouring  faint  and  sowne,  these  bee  unluckie 
and  mortall  signes." 

The  third  chapter  of  this  Book  is,  in  some  respects,  the 
most  important  and  the  most  interesting  of  the  whole  work,  for 
it  deals  with  "  howe  a  woman  with  childe  shal  use  her  selfe, 
and  what  remedies  be  for  them  that  have  harde  labour."  If 
there  should  be  any  disease,  swelling,  or  apostumation  (abscess) 
about  the  uterus,  vulva,  or  bladder  (such  as  stone  or  strangury), 
then  "  in  these  cases  it  behoveth  such  thynges  to  be  loked  unto 
and  cured  before  the  time  of  laboure  commeth,  by  the  advise  of 
some  expert  Surgion."  Her  diet x  before  labour  will  be  different 
from  that  during  labour.  If  there  be  constipation,  she  must 
use  "suche  thinges,  the  whiche  may  lenifie,  mollifie,  dissolve, 
and  lose  the  belly :  as  apples  fried  with  suger  taken  fastynge  in 
the  mornynge,  and  after  that  a  draught  of  pure  wyne  alone, 
or  elles  tempred  with  the  juyce  of  swete  and  very  rype  apples. 
Also  to  eate  figges  in  the  mornynge  fasting,  and  at  nyght, 
looseth  'well  the  bellye.  If  these  profite  not,  Cassia  fistula 
taken  iii.  or  iv.  drams  one  halfe  hour  before  diner,  shal  loose 
the  belly  without  parel."  The  woman  also  must  refrain  from 
taking  constipating  things  ("  hard  egges,"  etc.),  and  it  may  be 
necessary  for  her  to  get  a  clyster,  "  but  it  must  be  very  gentle 
and  easye."  An  easy  and  temperate  purgation  (as  by  mercury) 
may  be  needed,  "or  elles  a  suppositar  tempered  with  sope, 
larde,  or  the  yolke  of  egges."  If  she  be  faint  or  sickly  just 
before    her   labour,   "then   must    ye   comfort   her  with   good 

1  Diet  here  means  course  of  living  and  not  simply  the  food  or  drink 
taken. 


270  THE  "BYRTH  OF  MANKYNDE," 

comfortable  meate,  drinke,  holsome  and  noble  electuaries." 
Various  ointments  and  baths  are  to  be  used  before  labour: 
"  Annointmentes  wherewith  ye  may  sople  the  privie  place, 
be  these.  Hennes  grese,  Duckes  grese,  Goose  grese,  also 
oyle  Olife,  Linsede  oyl,  or  oyl  of  Fenegreke,  or  the  visco- 
site  of  holyoks."  She  is  to  bathe  in  water  in  which  have  been 
seethed  "Malowes,  Holyoke,  Camomel,  Mercury,  Maiden- 
haire,  Lyneseede,  Fenegreke  seede,  and  such  other  thynges 
which  have  vertue  to  mollifie  and  sople."  If  she  be  not  able  to 
take  such  baths,  she  must  sponge  herself  with  the  water  and 
apply  ointments  locally.  Sweet  fumes  also  are  useful:  "it 
shalbe  also  very  profitable  for  her,  to  suffume  the  nether  places 
with  muske,  Ambre,  Gallia,  Muscata,  which  put  on  embres, 
yelde  a  goody  savoure,  by  the  whiche  the  neather  places  open 
theymselfe,  and  drawe  downwarde."  She  must  also  "  exercyse 
the  bodye  in  doing  some  thinge,  styring,  moving,  goynge,  or 
standinge,  more  then  otherwise  she  was  wont  to  doe." 

Hints  are  given  as  to  what  must  be  done  when  labour  pains 
come  on.  "  To  withstand,  defend,  and  to  put  away  so  neare  as 
mai  be  the  instant  and  present  dolours.  And  as  touchinge 
this  poynt,  it  shalbe  verye  profytable  for  her,  for  the  space  of 
an  houre  to  syt  styll,  then  (rysynge  agayne)  to  goe  up  and 
downe  a  payre  of  stayres,  crying  or  reaching  so  loude  as  she 
can,  so  to  styre  her  selfe." 

Here  follows  the  oft-quoted  passage  about  the  "womans 
stoole "  or  "  obstetric  chair  "  which  is  represented  in  the  Birth 
Figures.  "Nowe  when  the  woman  perceaveth  the  Matrix  or 
Mother  to  ware  laxe  or  loose,  and  to  be  dissolved,  and  that  the 
humours  yssue  foorth  in  great  plentie,  then  shall  it  be  mete 
for  her  to  sit  downe  leaninge  backwarde  in  maner  upright. 
For  the  which  purpose  in  some  regions  (as  in  Fraunce  and 
Germany)  the  Midwyfes  have  stoles  for  the  nonce,  whiche 
beynge  but  lowe,  and  not  hye  from  the  grounde,  be  made  so 
compasse  wyse  and  cave  or  holowe   in  the  middes,  that  that 


BY  DR   J.    W.    BALLANTYNE.  271 

mai  be  receaved  from  underneth  which  is  looked  for,  and  the 
backe  of  the  stole  leaning  backeward,  receaveth  the,  back  of 
the  woman,  the  fashion  of  the  which  stole,  is  set  in  the  begin- 
ning of  the  birth  figures  hereafter.  And  when  the  tyme  of 
laboure  is  come,  in  the  same  stoole  ought  to  be  put  many 
clothes  or  cloutes  in  the  back  of  it,  the  which  the  Midwife 
may  remove  from  one  syde  to  another  accordinge  as  necessitie 
shall  require.  The  Midwyfe  her  selfe  shall  syt  before  the 
labourynge  woman,  and  shall  diligentlye  observe  and  wayte, 
howe  much,  and  after  what  meanes  the  chylde  styreth  it  selfe, 
also  shall  with  her  handes  fyrste  annoynted  with  the  oyle  of 
Almondes,  or  the  oyle  of  whyte  Lyllies,  rule  and  dyrecte  every 
thyng  as  shall  seme  beste.  Also  the  mydwife  muste  enstructe 
and  comfort  the  partie,  not  only  refreshing  her  with  good 
meate  and  drink,  but  also  with  swete  woordes,  gevynge  her 
good  hope  of  a  spedefull  delyveraunce,  encouraginge  and 
enstomakinge  her  to  pacyence  and  tolleraunce,  byddynge  her 
to  holde  in  her  breath  so  much  as  she  may,  also  strekinge 
gentilly  with  her  handes  her  bellye  above  the  Navell,  for 
that  helpeth  to  depresse  the  birth  downewarde." 

If  the  patient,  however,  be  fat,  the  writer  recommends 
that  she  "  lye  grovelynge,"  and  if  necessity  require  it  "  let  not 
the  midwife  bee  afrayde  ne  ashamed  to  handle  the  places,  and 
to  relax  and  loose  the  straites  (for  so  muche  as  shal  lye  in 
her),  for  that  shal  helpe  wel  to  the  more  expedite  and  quicke 
labour."  She  is  warned,  however,  against  interfering  too  soon 
"  before  the  byrth  come  f  orwarde,"  and  she  ought  not  to  allow 
the  patient  to  expend  her  strength  before  the  proper  time. 
When  the  bag  of  membranes  appears,  "  then  maye  ye  knowe 
that  the  labour  is  at  hand."  If  the  bag  do  not  burst  of  its  own 
accord,  "it  shalbe  the  Mydwyfes  part  and  office,  with  the 
nayles  easely  and  gen  telly  e  to  breake  and  rent  it,  or  yf  that 
may  not  conveniently  be  done,  then  rayse  up  betwene  your 
fyngers  a  peece  of  it,  and  cut  it  with  a  payre  of  shieres,  or  a 


272  THE  "BYRTH  OF  MANKYNDE," 

sharpe  knyfe,  but  so  that  ye  hurt  not  the  byrth  with  the  cut." 
If  the  membranes  have  ruptured  or  been  ruptured  too  early, 
a  dry  labour  results  requiring  the  application  of  "oyle  of 
why te  Lyllyes  or  some  of  the  greses  spoken  of  before "  to  the 
parts;  "but  chiefely  in  these  difficulties  should  profite  the 
whyte  of  an  egge  together  with  the  yolke  powred  into  that 
same  place :  which  shoulde  cause  it  to  be  most  slyppery  and 
slydynge,  and  supplye  the  roome  of  the  naturall  humidities 
spent  before." 

The  birth  of  a  child  with  a  large  head  or  of  twins  is  to  be 
assisted  by  the  midwife,  who  is  to  "  helpe  all  that  she  maye, 
with  her  hande  fyrste  annoynted  with  some  oyle  openying  and 
enlargyng  the  waye  that  the  issue  maye  be  the  freer." 

So  far  the  writer  has  been  dealing  with  the  "  natural  byrth 
when  that  first  proceadeth  the  head,"  as  is  represented  in  the 
first  of  the  Birth  Figures.  He  now  describes  in  turn  the  various 
ways  in  which  the  infant  or  infants  may  present,  and  in  what 
manner  the  midwife  is  to  treat  them.  In  the  second  of  the 
Birth  Figures  a  child  is  represented  coming  feet  first  (the 
attitude  of  the  foetus  is  wrongly  represented,  as  it  is  indeed  in 
most  of  the  figures),  and  in  such  circumstances  the  midwife  is 
apparently  directed  to  perform  cephalic  version  !  Here,  at  any 
rate,  are  the  directions :  "  Sometime  it  chaunced  the  child  to 
come  the  legges  and  both  armes  and  handes  downwarde,  close 
to  the  sydes  fyrst  foorth,  as  appeareth  in  the  seconde  of  the 
byrth  figures.  In  this  case  the  Mydwyf  e  must  do  all  her  payne 
with  tender  handlynge  and  annoyntyng  to  receave  foorth  the 
chylde,  the  legges.  beynge  styll  close  together  and  the  handes 
lykewyse  remaynynge  as  appeareth  in  the  seconde  figure. 
Howbeit,  it  were  farre  better  (yf  it  may  be  done  by  anye 
possible  wayes  or  meanes)  that  the  Mydwyfe  shoulde  tourne 
these  legges  commyng  fyrst  foorth,  upwardes  agayne  by  the 
bellywarde,  so  that  the  head  myght  descende  downewarde  by 
the  backe  parte  of  the  wombe :  for  then  naturally  agayne  and 


BY   DR   J.    W.    BALLANTYNE.  273 

without  peryl    might  it  proceade    and    come    forth    as   the 
fyrste." 

In  the  third  of  the  Birth  Figures  the  foetus  is  represented 
as  coming  by  the  feet  with  the  arms  displaced  upward  along- 
side of  the  head.  "This  is  the  perylloust  maner  of  byrth" ; 
and  the  direction  is  that  the  midwife  must  do  what  she  may 
"  to  turne  the  byrth  (yf  it  may  be  possible)  to  the  first  figure," 
but  no  directions  are  given  as  to  the  way  in  which  this  is  to  be 
done.  If  she  cannot  do  this,  she  is  directed  to  convert  it  into 
the  second  figure  by  bringing  down  the  hands ;  and  "  if  this 
also  wyll  not  bee,  then  receave  the  feete  as  they  come  foorth, 
and  bynde  them  with  some  fayre  linnen  cloth,  and  so  tenderly 
and  very  softly  lose  out  the  byrth  tyll  all  be  come  foorth, 
and  this  is  very  jeoperdous  labour."  When  one  foot  only 
presents  {Birth  Figure  IY.)  version  by  the  postural  method  ("  the 
labouring  woman's  head  to  be  the  lower  part  of  her  body") 
is  to  be  followed ;  but  if  it  do  not  succeed,  the  midwife  is  to 
bring  down  the  other  foot.  The  fifth  Birth  Figure  represents, 
rather  crudely,  a  transverse  presentation ;  the  sole  direction 
for  its  management  is :  "  then  must  the  Mydwyfe  do  so,  that  it 
may  be  returned  to  his  naturall  fashion,  and  so  to  come  foorth." 
The  sixth  and  seventh  cases  call  for  no  special  comment.  The 
eighth  Birth  Figure  shows  descent  of  one  of  the  arms  alongside 
of  the  head ;  under  these  circumstances  the  midwife  is  told  to 
thrust  the  birth  in  again,  and  if  this  fail  she  is  to  try  postural 
treatment ;  the  same  procedure  is  to  be  adopted  in  the  ninth 
mode  of  presentation  when  both  hands  come  down.  The 
directions  for  the  management  of  a  breech  case  {Birth  Figure  X.) 
are  surprising:  "Then  must  the  Mydwyfe  with  her  handes 
returne  it  agayne,  untyll  such  tyme  that  the  birth  be  turned, 
the  legges  and  feete  forwarde."  A  shoulder  presentation  is 
shown  in  Birth  Figure  XII.  (described  erroneously  in  the 
text  as  XI.),  and  the  direction  is,  "  then  must  ye  fayre  and 
softly  thrust  it  back  agayne  by  the  shulders,  tyll  suchetyme  as 

S 


274  THE   "  BYRTH   OF    MANKYNDE/' 

the  heade  come  forwarde."  Twin  cases  are  shown  in  the  Birth 
Figures  XIV.,  XV.,  and  XVI. ;  in  the  first  are  two  heads,  in 
the  second  two  breeches,  and  the  third  is  a  head  and  a  breech 
presentation.  In  the  description  appended  to  the  last-named 
mode  of  labour  there  is  the  suggestion  that  the  possibility  of 
head-locking  was  not  unknown  to  the  writer. 

On  the  whole,  it  must  be  admitted  that  the  management  of 
labour  as  set  forth  in  this  chapter  falls  far  behind  modern 
practice,  not  to  say  theory.  The  notions  regarding  the  attitude 
of  the  foetus  in  utero  were  erroneous,  the  distinctions  between 
the  various  presentations  were  incomplete  {e.g.,  face  cases  are 
not  figured  or  named),  and  the  management  not  infrequently 
consisted  in  interfering  in  the  cases  which  we  should  now  leave 
alone  and  in  using  ointments  and  posture  under  circumstances 
in  which  more  radical  methods  would  now  be  adopted.  One 
cannot  help  wondering  also  how  the  midwives  carried  out  the 
.  instructions  given  to  them ;  certainly  they  were  not  burdened 
with  details. 

The  fourth  chapter  (wrongly  described  as  the  fifth  in  this 
edition  of  1650)  deals  with  "  the  remedies  and  medicines  by  the 
which  the  labour  may  be  made  more  tollerable,  easy,  and 
without  great  payne."  The  posture  of  the  patient,  the  tempera- 
ture of  the  lying-in  room,  the  provocation  of  sneezing  ("  and 
that  eyther  with  the  powder  of  Meborus1  or  els  of  pepper"), 
and  the  use  of  ointments  are  all  referred  to.  Of  the  oils, 
ointments,  perfumes,  washes,  drinks,  pills,  and  plasters  mentioned 
in  this  chapter,  we  need  mention  two  only.  Here  is  a  perfume  : 
"  Take  yelowe  brymstone,  Myrre,  Mader,  Galbanum,  Oppopona- 
cum,  of  eche  lyke  much,  and  tempre  all  those  together,  makynge 
of  them  pylles,  and  with  those  also  ye  maye  make  fume,  to  be 
receaved  underneath."  The  chapter  closes  with  the  prescrip- 
tion of  "a  plaster  to  provoke  the  birth."     Here  it  is:  "Take 

1  Eleborus,  Hellebore,  White  Hellebore  ( Veratrum  album),  was  used 
as  a  sternutatory. 


BY   DR   J.    W.  BALLANTYNE.  275 

wylde  Gowarde,1  and  seeth  it  in  water,  in  the  same  water 
temper  Myrre,  the  juyce  of  Rue,  and  Barlye  meale  so  much  as 
shalbe  sufficient,  stampe  these  thynges  together,  and  make  it 
plasterwyse,  then  laye  it  to  the  womans  bellye  betwene  the 
Navyll  and  the  nether  parte.  This  plaster  shall  helpe  mar- 
veylously." 

Chapter  V.  is  concerned  with  "howe  the  secondine  or 
seconde  byrth  shalbe  forced  to  issue  foorth,  if  it  come  not  freely 
of  his  owne  kynde."  Various  causes  of  the  non-expulsion  of 
the  placenta  and  membranes  are  enumerated,  such  as  lack 
of  strength  from  prolonged  labour,  "  entanglement "  of  the 
secondines  within  the  uterus,  and  swelling  of  the  parts.  The 
dangers  of  placental  retention  are  also  named,  and  include 
"  suffocation  and  chokinge  of  the  Matrix "  and  putrefaction  of 
the  after-birth.  "  The  seconde  birth  retayned  and  kept  within 
will  soone  putrifie  and  rot :  whereof  wyll  ensue  yll  noysom  and 
pestiferous  vapoures  ascendinge  to  the  heart,  the  braynes  and 
the  midriffe,  through  the  which  meanes  the  woman  shalbe 
short  wynded,  faynte  harted,  often  soundinge  and  lyinge  with- 
out any  maner  of  movynge  or  styrringe  in  the  pulces :  yea,  and 
many  tymes  is  playnely  suffocated,  strangled  and  dead  of  it." 
The  remedies  proposed  for  non-expulsion  of  the  placenta  were 
founded  to  some  extent  upon  the  causal  conditions  so  far  as 
these  were  understood.  If  weakness  from  long  labour  were 
the  cause,  then  must  the  "labourer"  be  "recomforted  and 
strengthed  with  good  comfortable  meates  and  drinkes,  which 
maye  enhart  her,  as  broath  made  of  the  yolcke  of  egges,  or  with 
good  olde  wine,  and  good  fat  and  tidie  fleshe,  or  Byrdes,  Hennes 
fleshe,  Capons,  Partrige,  Pigins  and  such  like."  If  the  cause 
were  contraction  of  the  passages,  then  oils  and  ointments 
are  recommended  to  "  make  the  waye  slypper,  sople,  and  easy 
for  it  to  proceade."  Perfumes,  also,  and  vapours  are  said  to  be 
efficacious.  "But  if  the  retencion  of  the  secondine  come  by 
1  Gowarde,  Wild  Gourd,  Colocynth. 


276  THE   "BYRTH   OF   MANKYNDE," 

reason  that  it  is  entangled  or  fastened  in  some  place  of  the 
Matrix,  so  that  it  wyll  not  resolve  ne  loose ;  then  make  a  fume 
underneath  of  Brimstone,  Ivie  leaves,  and  Cresses,  or  elles  of 
Cresses  fygges."  There  are  some  curious  restrictions,  of  which 
the  following  is  an  instance:  "Also  of  all  odoriferous  and 
sweete  smellinge  thinges,  as  Ambre,  Muske,  Frankencense, 
Gallia  Miiscata,  and  confection,  neare  the  which  savoures  and 
perfumes  put  on  the  embers  muste  be  so  closely  receaved 
underneth,  that  no  part  of  the  smell  do  ascende  to  the  nose 
of  the  woman.  For  to  the  nose  shoulde  the  savoure  of  nothynge 
come,  but  onely  of  suche  thinges,  the  which  stinke  or  have 
abhominable  smell,  as  Asafetida,  Castorium,  mans  hayre  or 
womens  hayre  burnt,  Pecockes  fethers  burnt."  "  Item  let  her 
be  provoked  to  sneese  with  the  powder  of  Eleborus  or  Pepper 
put  in  the  nose,  holdinge  her  mouth  and  nose  so  close  as 
maye  be." 

The  following  directions  for  the  removal  of  the  after-birth 
are  interesting:  "And  yf  it  bee  so  that  any  parte  of  the 
secondine  do  appeare,  let  the  Mydwife  receave  it  tenderly, 
losynge  it  out  fayre  and  softly,  least  it  breake,  and  if  ye  doubt 
that  it  wil  breake,  then  let  the  Mydwife  tye  that  parte  of  the 
whiche  she  hath  handfast  to  the  womans  legge  or  fote,  not 
very  strayght,  least  it  breake,  nether  very  lax,  least  it  slip  in 
agayne,  and  then  cause  her  to  sneese.  Nowe  yf  the  secondine 
tarye  or  stycke,  so  that  it  come  not  quickly  forewarde,  then 
loose  it  a  lyttle  and  a  lyttle  very  tenderly,  wrethinge  it  from 
one  syde  to  another,  tyll  such  time  as  it  be  gotten  out,  but  ever 
beware  of  violent  and  hasty  movynge  of  it,  leaste  that  with 
the  seconde  byrth  ye  remove  the  Matrix  also."  The  danger  of 
inversion  of  the  uterus  is  doubtless  alluded  to  in  this  last 
passage.  The  chapter  closes  with  directions  for  a  fumigation 
and  a  plaster,  and  with  the  following  somewhat  despairing 
instruction :  "  If  for  al  this  the  secondine  come  not  forewarde, 
then  leave  it,  and  use  no  more  medicines  ne  remedyes  to  that 


BY  DR  J.    W.    BALLANTYNE.  277 

purpose,  but  let  it  alone,  for  within  fewe  days  it  wyll  putrifie 
and  corrupt,  and  dissolve  into  a  watery  substaunce,  thick  like 
bryne,  or  other  fex  myxed  with  water,  and  so  yssue  foorth. 
Howbeit  in  the  meane  whyle  it  wyll  put  the  woman  to  great 
paine  in  the  head,  in  the  heart,  and  in  the  stomacke,  as  we 
touched  before." 

The  sixth  chapter  is  a  long  one,  dealing  with  such  important 
matters  as  "howe  many  thinges  chaunce  to  the  women  after 
theyr  laboure,  and  how  to  avoyde,  defende,  or  to  remedye  the 
same."  Among  the  "many  thinges"  are  "the  fever  or  ague 
or  swelling,  or  inflation  of  the  bodye,  other  tumblynge  in  the 
belly,  or  elles  commotion  or  settelinge  out  of  order  of  the 
Mother  or  Matrix,"  and  the  cause  of  these  is  sometimes  "  lacke 
of  due  and  sufficient  purgation  and  clensynge  of  the  flowres 
after  the  byrth,  or  els  contrarywyse  over  muche  flowinge  of 
the  same,  whiche  sore  doth  weaken  the  woman,  also  the  great 
labour  and  styrrynge  of  the  Matrix  in  the  byrth." 

The  "  ague  "  we  may  shrewdly  suspect  was  septic  poisoning, 
"  for  that  commeth  of  like  cause  by  retention  of  the  flowres." 
The  patient  is  then  to  "  drinke  water  in  the  whiche  is  decocte 
Barley  beaten,  or  Cicer1  and  Barley  together,  or  water  in 
whiche  be  sodden  Tamarindi,  or  whaye  of  mylke,  and  let  her 
eate  Cullis2  made  of  a  Cocke,  and  sweete  Pomegarnates,  for 
these  thynges  do  provoke  the  flowres,"  etc.  Various  remedies, 
resembling  those  already  referred  to,  are  to  be  given  in  such 
conditions  as  swelling  of  the  body,  "frettinge  and  knawynge 
of  the  guttes,"  "  paine  in  the  privie  partes,"  "  outragious  flux  of 
flowres,"  "coming  forth  of  the  fundament  gut,"  and  the  like. 
It  is  unnecessary  to  describe  in  detail  the  curious  plans 
adopted  and  mixtures  administered  in  these  cases,  one  instance 
must  serve  for  all:  "To  stynte  and  restrayne  the  outragious 
fluxe   of  flowres,  it   shalbe  verye  good   to   binde   the    amies 

1  Cicer,  a  chick-pea. 

2  Cullis,  a  strong  broth,  a  beef -tea. 


278  THE  "BYKTH   OF  MANKYNDE," 

strayght  and  strongly,  and  not  the  feete  or  handes,  as  some 
unwyse  men  doe  teache,  and  then  to  set  a  ventose  boxe,  or 
cupping  glasse  with  fyre  (which  is  called  borying)  under  the 
brestes  without  anye  scarification."  Here  is  one  of  the 
plasters:  "Take  of  the  bloud  stone  called  Emathites,  Bole 
armeniacke  of  eche  halfe  an  ounce,  Sanguis  draconis,  Licium, 
of  eche  twoo  drammes,  Karabe,  otherwye  named  Ambre,  the 
cuppes  of  Acornes,  Cipres  tree  nuttes,  flowres  of  Pomegranade, 
of  eche  one  dram,  of  the  scales  of  Iron  one  dram  and  a  halfe, 
Turpintine  and  Pitch  lyke  quantitie,  or  so  much  as  shalbe 
sufficient  to  make  a  softe  and  somewhat  liquid  plaster." 

The  next  chapter  (the  seventh)  deals  with  "  aborcementes 
or  untymelye  byrthes,  and  the  causes  of  it,  and  by  what 
remedies  it  may  be  defended,  holpen,  and  eased."  Many 
curious  causes  are  enumerated,  among  which  is  "a  disease 
called  Tenasmus,  the  which  is  when  hath  ever  greate  desyre 
and  luste  to  the  stool,  and  yet  can  do  nothynge."  Other 
causes  are  coughing,  bleeding  at  the  nose,  "to  be  let  bloud," 
strong  purgation,  hunger,  cold,  heat,  etc.  "Therefore  ought 
women  with  chylde  to  eschewe  much  bathyng  or  going  to 
the  hotte  houses  in  theyr  teming"  (teeming).  "Item,  the 
intemperancie  and  mutation  of  the  ayre  and  weather  may  be 
cause  of  aborcement,"  and  after  this  statement  there  follows 
an  interesting  paragraph  on  meteorology  in  its  relation  to 
health,  as  it  was  then  understood.  "Dancing  and  leaping" 
are  also  named  as  possible  causes,  and  so  are  "  sodayne  anger, 
feare,  dread,  sorowe,  or  some  sodaine  and  unloked  for  joy." 

To  the  modern  reader  the  signs  of  abortion  enumerated  by 
the  writer  of  the  Byrth  of  Manhynde  will  appear  most  astonish- 
ing and  unconvincing ;  among  them  he  will  find  "  a  great  ache 
in  the  inner  part  of  the  eies  toward  the  braynes,"  redness  of 
the  face,  "  ventositie  or  wynde  runnynge  from  one  syde  of  the 
bodye  to  the  other."  kt  the  same  time  there  is  a  reference, 
but  a  very  brief  one,  to  the  really  important  sign  of  "greate 


BY  DR   J.    W.    BALLANTYNE.  279 

paynes  and  dolours  of  the  Matrix."  The  means  of  diagnosis 
given  are  hardly  such  as  to  justify  the  author's  confident 
assertion :  "  thus  have  I  sufficently  declared  evident  sygnes, 
whereby  may  be  provyded  and  foreseene  the  aborcement  before 
it  come."  The  methods  of  treatment  are  those  which  we  now 
have  come  to  look  for  from  our  author, — baths,  fumigations, 
plasters,  ointments,  odours,  and  such  like;  but  he  gives  the 
midwife  one  good  piece  of  advice:  "Howbeit,  in  all  thys 
matter,  let  not  to  make  some  expert  Phisition  of  youre  counsaile, 
yf  ye  may  have  suche  one :  for  because  that  manye  such  thinges 
come,  and  not  all  by  one  way  or  meane." 

The  eighth  chapter  (wrongly  named  the  ninth  in  the  edition 
of  1560)  is  concerned  with  "dead  byrthes,  and  by  what  sygnes 
or  tokens  it  maye  be  knowen,  and  by  what  meanes  it  may  also 
be  expelled."  The  signs  are  twelve  in  number ;  but  they  are 
not  very  convincing,  as  may  be  gathered  when  it  is  noted  that 
the  twelfth  sign  is,  if  the  mother's  "handes  put  into  very  warme 
water,  and  then  laycle  on  the  belly,  and  the  childe  steare  not." 
There  is  evidence  of  sound  knowledge,  however,  in  the  statement 
that  "  of  all  these  sygnes  nowe,  the  more  that  come  togeather  of 
theym  at  one  tyme  and  in  one  person,  the  surer  maye  ye  be 
that  the  byrth  is  dead." 

The  prognosis,  grave  or  favourable,  in  cases  of  dead-birth 
labours  is  set  forth :  "  Whether  the  Mother  shalbe  in  parell 
or  no,  by  these  thinges  shall  ye  knowe.  If  the  woman  beynge 
in  the  laboure  sowne  or  feare  as  though  she  were  in  a  transe : 
yf  her  remembraunce  fayle  her,  and  she  were  feble  and  scante 
able  to  moue  or  styre  herselfe,  yf  she  (called  with  a  loud  voyce) 
canne  aunswere  nothinge  at  all,  or  elles  verye  lyttle,  and  that 
verye  softely,  as  though  her  voyce  began  to  fayle  her :  if  she 
be  invaded  or  taken  among  in  the  labouring  with  convulsion  or 
shrinkelynge  together :  if  she  refuse  or  cannot  brooke  meat :  yf 
her  pulces  beat  every  faste,  the  which  signes  when  ye  se  in  the 
woman  labouringe,  it  is  an  evident  token  that  she  shal  not  lyve 


280  THE  "BYRTH  OF  MANKYNDE," 

longe  after  her  delyveraunce,  wherefore  commit  the  cure  of  her 
to  the  handes  of  almyghtie  God." 

The  treatment  consists  in  getting  ride  of  the  "  dead  burthen  " 
either  by  "  medicines  expulsy ve  "  or  else  by  certain  instruments 
made  "  for  the  nonce."  Here,  again,  we  find  described  a  long 
list  of  fumigations,  containing  such  things  as  the  hoof  or  dung 
of  an  ass,  the  skin  of  an  adder,  "hawkes'  dung"  or  "oxe  gall," 
of  suppositories  or  pessaries,  of  drinks  ("  yf  the  woman  drynke 
the  mylke  of  another  woman,  it  will  styre  and  expell  the 
byrthe  "),  and  of  plasters.  "  But  yf  all  these  medicines  profyt 
not,  then  must  be  used  more  severe  and  harde  remedyes,  with 
instrumentes  :  as  hokes,  tounges,  and  suche  other  thinges  made 
for  the  nonce."  From  the  wording  of  the  directions  it  is 
evidently  intended  that  the  midwife  herself  shall  fix  the  hooks 
into  the  eyes,  or  mouth,  or  shoulders,  or  ribs  of  the  dead  foetus 
and  make  traction,  other  women  keeping  the  patient  down. 
Arms  and  legs  are  to  be  cut  off,  if  need  be,  and  the  head  is  to 
be  opened  with  a  sharp  penknife  if  it  be  much  swollen.  Both 
the  head  and  trunk  may  have  to  be  broken  up  into  pieces  with 
"  such  instrumentes  as  the  Chirurgions  have  readye  and  neces- 
sarye  for  suche  purposes." 

The  last  paragraph  of  this  chapter  must  be  quoted  entire : 
"  But  contrary  to  all  this,  yf  it  chaunce  that  the  woman  in  her 
labour  dye,  and  the  chylde  having  lyf e  in  it :  then  shal  it  be 
meete  to  kepe  open  the  womans  mouth,  and  also  the  nether 
places ;  so  that  the  chylde  may  by  that  meanes  both  receave 
and  also  expell  ayre  and  breath,  which  otherwyse  myght  be 
stopped,  to  the  destruction  of  the  chylde.  And  then  to  turne 
her  on  the  lefte  syde,  and  there  to  cut  her  open,  and  so  to  take 
out  the  chylde.  They  that  be  borne  after  this  fashion  are  called 
Cesares,  for  because  they  be  cutte  out  of  theyr  mothers  belly : 
whereupon  also  the  noble  Komayne  Cesar  the  fyrste  toke  his 
name."  Assuredly  the  directions  given  here  for  a  post-mortem 
Cesarean  section  are  not  too  explicit ! 


BY  DR  J.    W.   BALLANTYNE.  281 

Chapter  IX.  (by  error  called  Chapter  X.  in  the  Kaynalde 
editions)  has  no  representative  in  the  1540  edition  or  in 
Kosslin's  De  Partu  Hominis,  and  we  must,  therefore,  ascribe  it 
to  Kaynalde.  It  contains  a  list  of  medicines,  ointments,  and 
plasters  ("  suche  as  hath  ben  wel  experimented  and  practysed  "), 
to  be  used  to  quicken  delivery  and  to  expel  the  after-birth.  The 
reader  is,  by  this  time,  able  to  foretell  pretty  accurately  what 
kind  of  drugs  will  be  in  these  medicines,  and  I  need  only  refer 
to  certain  "  trochiskes  "  upon  which  the  writer  evidently  places 
much  reliance.  "  Item,  of  Saffron  dried  by  the  fyre  tyl  it  be 
blackyshe,  of  Cassia  lignea,  fine  Keubarbe,  Savine  dryed, 
Myrreh,  of  eche  of  these  seven  scruples,  of  pure  muske,  xvi. 
graynes,  every  of  these  simples  exquisitely  by  them  selves 
powdred,  and  then  perfectlye  myxed  in  one,  with  vi.  or  vii. 
droppes  of  Malvesey,  temper  the  whole  mase  into  lyttle 
roundels  or  trochiskes,  eche  waying  a  dram.  And  in  tyme  of 
neede  at  the  womans  labour,  geve  her  hardly  the  wayght  of  vi. 
d.  of  these  trochiskes  beaten  into  fine  powder,  with  foure 
sponefulles  of  Isope  water,  and  other  foure  of  good  wine  secke." 
The  chapter  closes  with  a  paragraph  (to  which  I  have  referred 
in  my  previous  article  as  the  "  Bucklersbery  paragraph")  telling 
where  the  "  trochiskes  "  are  to  be  obtained. 

Such  are  the  contents  of  the  Second  Book  as  they  appear  in 
the  1560  edition.  There  are  slight  verbal  differences  in  some 
of  the  other  editions,  and  these  specially  affect  the  "  Bucklersbery 
paragraph."  More  distinct  variations  separate  the  1540  or 
Jonas  editions  from  that  of  1560  and  from  the  rest.  The 
whole  of  the  ninth  chapter  (erroneously  called  the  tenth)  is 
absent  from  the  1540  edition ;  there  is  a  difference  in  the 
wording  of  the  commendation  of  the  "plaster  to  provoke  the 
birth,"  Jonas  being  less  certain  about  its  efficacy  than  Kaynalde, 
and  throughout  the  whole  book  Jonas  is  more  in  the  habit  of 
introducing  such  phrases  as  "Avicenna  saith"  or  "Hippocrates 
writeth  "  than  Kaynalde  (e.g.  in  Chapter  VIIL).     The  differences 


282  THE   "BYRTH   OF  MANKYNDE," 

are  simply  due  to  the  fact  that  Jonas  translated  Kosslin's  book 
literally,  whereas  Eaynalde  gave  a  more  free  rendering  and 
supplemented  the  work  here  and  there.  For  this  reason,  also, 
it  comes  about  that  the  Second  Book  of  the  Eaynalde  editions  is 
part  of  the  First  Book  of  the  Jonas  edition,  for  it  really 
represents  Chapters  II.  to  IX.  of  Kosslin's  De  Partu  Hominis. 
Jonas's  First  Book  corresponds  to  Chapters  I.  to  XL  of  Kosslin. 

The  "Byrthe  Fygures." 

The  "Byrthe  Fygures,"  including  the  "Woman's  Stoole," 
belong  to  the  Second  Book  of  the  1560  and  of  the  other 
Eaynalde  editions.  They  are  all  taken  from  Kosslin's  De 
Partu  Hominis,  but  they  are  not  placed  in  the  same  order. 
Further,  there  is  one  in  Kosslin's  book  which  does  not  appear  in 
the  1560  edition  (or,  so  far  as  I  know,  in  any  of  the  Kaynalde 
editions);  this  has  been  reproduced  in  Fig.  V.  It  will  be 
noted  that  in  some  respects  it  more  nearly  represents  the  true 
attitude  of  the  foetus  in  utero  than  any  of  the  others.  I  have 
reproduced  five  of  the  Kosslin  figures  (including  the  "  Stoole ") 
which  have  their  representatives  in  the  Kaynalde  editions 
(Figs.  YI.-X.),  so  that  the  reader  may  compare  them  with  the 
same  pictures  as  they  appear  in  the  English  translation  (see  my 
previous  article,  Plates  VIII.,  IX.,  X.,  and  XL).  I  have  already 
(loo.  cit.)  referred  to  the  great  interest  which  the  "  Byrth  Fygures  " 
of  the  Byrth  of  Manhynde  have  excited  as  being  the  earliest,  or 
almost  the  earliest,  specimens  of  English  copperplates. 

The  Third  Book. 

The  Third  Book  of  the  1560  edition  of  the  Byrth  of  Man- 
kynde  consists  of  three  chapters,  the  third  being  a  very  long 
one.  It  is  devoted  to  the  care  of  the  new-born  infant,  and  to 
its  "  dy verse  diseases  and  inf yrmities  "  :  the  first  chapter  speaks 


BY  DR   J.   W.    BALLANTYNE.  283 

of  the  umbilical  cord  and  its  management,  the  second  of  the 
nurse  and  her  milk,  and  the  third  of  the  maladies  of  infants 
and  the  remedies  required  for  them.  "Then  after  that  the 
Infant  is  once  come  to  lyght,  by  and  by  the  Navyll  muste  be 
cut  three  fyngers  breadth  from  the  belly,  and  so  knit  up,  and 
let  be  strued  on  the  head  of  that  remayneth,  of  the  powder  of 
Bole  armeniacke,  and  Sanguis  draconis,  Sarcocolla,  Myrrhe,  and 
Cummin,  of  eche  lyke  muche  beaten  to  pouder,  then  upon  that 
bynd  a  peece  of  woll,  dypped  in  oyle  Olive,  that  the  powder 
fall  not  of.  Some  use  fyrst  to  knyt  the  Navyl,  and  after  to  cut 
it  so  much,  as  is  before  rehearsed."  The  writer  mentions  the 
belief  that  the  length  of  the  stump  of  the  cord  will  determine 
the  length  of  the  "  chyldes  tonge,"  if  it  be  a  man-child.  He 
also  refers  to  Avicenna's  statement  that  the  wrinkles  on  the 
cord  betoken  the  number  of  future  pregnancies  the  patient  is  to 
have  and  the  intervals  of  time  (long  or  short)  between  them ; 
"  but  these  sayinges  be  nether  in  the  G-ospell  of  the  day,  ne  of 
the  night." 

The  child's  body  is  to  be  rubbed  with  oil  of  acorns.  "  After 
this  annoyntyng,  washe  the  Infante  with  warme  water,  and 
with  your  fynger  (the  nayle  beyng  pared)  open  the  chyldes 
nosethrilles,  and  purge  them  of  the  fylthiness."  After  the  fall 
of  the  cord  ("  whiche  commonlye  chaunceth  after  the  thyrde  or 
fourth  daye")  the  cicatrix  is  to  be  dusted  with  "ashes  of  a 
Calfes  hove  burnte,  or  of  Snayle  shelles,  or  of  the  powder  of 
lead,  called  red  lead,  tempered  with  wyne."  The  proper 
swaddling  of  the  child  is  then  described,  so  that  its  limbs  may 
grow  straight  ("as  it  is  in  yonge  and  tender  impes,  plantes, 
and  twygges ") ;  the  eyes  should  be  frequently  washed,  and  it 
should  sleep  in  its  cradle  in  such  a  place  that  neither  the 
beames  of  the  Sunne  by  day,  neither  of  the  Moone  by  nyght 
come  on  the  Infant."  It  is  to  be  washed  two  or  three  times  a 
day;  and,  after  that,  to  put  a  drop  or  two  of  water  into  its 
nostrils  is  "  very  good  for  the  eye  syght." 


284  THE   "  BYRTH    OF   MANKYNDE " 

"  It  shalbe  beste  that  the  mother  give  her  chylde  sucke  her 
selfe,  for  the  mothers  mylke  is  more  convenient  and  agreable  to 
the  infant,  than  any  other  womans,  and  more  doth  it  nouryshe 
it,  for  because  that  in  the  mothers  belly  it  was  wont  to  the  same, 
and  fed  with  it,  and  therefore  also  it  doth  more  desyrouslye 
covet  the  same,  as  that  with  the  which  it  is  best  acquainted." 
Apparently  the  nursings  are  not  to  be  frequent :  "  As  Avicenna 
writeth  it  shalbe  sufficient  to  give  sucke  twyse  or  thryse  in  a 
daye."  If  the  mother  be  unable  to  suckle  her  child,  then 
a  "  holsome  Nourse "  is  to  be  sought  out ;  five  or  six  essential 
qualities  are  enumerated  which  she  must  possess,  and  a  method 
of  testing  the  milk  upon  the  thumb  nail  is  described.  There 
is  a  long  list  of  remedies  which  are  said  to  increase  the  quantity 
of  the  milk.  Two  instances  must  serve :  "  Item,  to  eate  shepes 
brestes,  and  the  mylke  of  them  is  good " ;  "  Item,  take  two 
drams  of  Crystall  beaten  into  fyne  powder,  and  devyde  that  in 
f oure  equal  partes :  one  of  these  partes  geve  unto  the  Nourse, 
the  space  of  foure  dayes  to  drynke,  with  broth  made  eyther  of 
Cicer,1  or  elles  of  peason." 2  The  child  is  not  to  be  put  to  the 
mother's  breast  for  a  day  or  two  after  birth,  "  because  that  the 
creme  (as  they  cal  it)  straight  after  the  byrth,  the  first  day  in 
al  women  doeth  thicken  and  congile."  This,  it  need  hardly  be 
said,  is  not  the  rule  of  procedure  at  the  present  time.  Weaning 
should  take  place  at  the  end  of  the  year,  and  it  is  not  to  be 
carried  out  suddenly  but  gradually;  the  infant  is  not  to  be 
given  "lyttle  pylles  of  bread  and  sugar  to  eate"  until  it  be 
able  to  "  eate  all  maner  of  meate." 

The  third  chapter  of  this  book  is  taken  up,  as  has  been  said, 
with  the  diseases  of  infants  and  their  treatment.  It  is  of  interest 
rather  to  the  pediatric  physician  than  to  the  obstetrician ;  but 
I  may  enumerate  some  of  the  subjects  dealt  with :  "  loosenesse 
of  the  bellye,  cough  and  distillation,3  short  winde,  wheales  on 

1  Cicer,  chick-pea.  2  Peason,  pease. 

3  Distillation,  a  catarrh  or  defluxion  of  rheum. 


BY   DR   J.    W.    B ALLAN TYNE.  285 

the  tounge,  apostumation  and  runninge  of  the  eares,  bolnynge1 
of  the  eyes,  often  sneesinge,  whelkes  in  the  body,  swelling  of 
the  coddes,2  unslepinesse,  yeringe  or  the  hyckate,3  terrible 
dreames,  wormes  in  the  belly,  the  fallynge  syckenes,  the  palsey, 
and  gogle  eyes  4  or  loking  squint."  It  is  unnecessary  to  quote 
the  means  recommended  for  the  treatment  of  these  various 
maladies,  but  the  following  prescription  for  the  falling 
sickness  (epilepsy)  may  be  given  by  way  of  sample:  "Item, 
to  hange  Viscum  quersinum,5  which  is  gathered  in  Marche 
the  moone  decreasynge,  about  the  Chyldes  necke,  is  very 
good." 

The  Third  Book  as  it  appears  in  the  1560  edition  differs 
little  from  what  it  is  in  the  other  Eaynalde  issues,  earlier  or 
later.  I  have  found  a  few  verbal  differences  between  it  and  the 
1552  edition  (e.g.,  in  the  paragraph  on  "  Unsleppynesse "),  and 
in  the  1654  edition  there  is  a  new  chapter  (placed  quite  at  the 
end  of  the  work)  amplifying  what  has  been  said  about  the 
nursing  of  children  and  "  how'  to  choose  a  good  nurse."  The 
1540  edition  differs  more  markedly:  the  chapter  on  "unsleepi- 
ness"  is  shorter,  that  on  swelling  of  the  coddes  is  not  the 
same;  there  are  two  additional  short  paragraphs  (the  one 
"  against  the  mother,"  and  the  other  of  short  breath,  hoarseness, 
or  whistling  in  the  throat),  and  there  is  an  additional  sentence 
on  infantile  constipation. 

The  Third  Book  of  the  Eaynalde  editions  corresponds  to 
Chapters  X.  and  XI.  of  the  First  Book  and  to  the  whole  of  the 
Second  Book  of  the  1540  or  Jonas  edition.  It  forms,  also,  the 
tenth,  eleventh,  and  twelfth  chapters  of  Be  Tartu  Hominis, 
from  p.  61  to  the  end  (in  the  edition  of  1538). 


1  Bolnynge,  swelling  or  a  tumour. 

2  Coddes,  testicles. 

3  Hyckate  or  yexing,  the  hiccup. 

4  Gogle  eyes,  staring  eyes  or  squint  eyes. 

,r>  Viscum  quersinum,  mistletoe  of  the  oak. 


286  THE   "BYRTH   OF   MANKYNDE,' 


The  Fourth  Book. 

The  Fourth  Book  of  the  1560  as  well  as  of  the  other 
Kaynalde  editions  consists  of  six  chapters ;  these  are  not  found 
in  Kosslin's  De  Partu  Hominis,  but  five  of  them  are  present  in 
the  1540  or  Jonas  edition  of  the  Byrth  of  Mankynde,  so  that 
only  one  (the  sixth)  chapter  is  peculiar  to  the  Baynalde 
editions.  The  Fourth  Book  of  the  1545  and  of  all  later 
editions  corresponds  to  the  Third  Book  of  the  1540  or  first 
impression. 

An  idea  of  the  subjects  dealt  with  in  the  Fourth  Book  can 
best  be  obtained  from  the  short  summary  contained  in  the 
first  chapter.  I  quote  (in  this  instance)  from  the  1552  edition : 
"  Here  in  this  fourth  Boke  (by  ye  leave  of  God)  shal  brefely  be 
declared  soch  thinges  which  may  farther  or  hinder  the  con- 
ception of  man,  whych  as  it  may  be  by  dyvers  meanes  letted 
and  hyndered,  so  also  by  many  other  wayes  it  may  be  farthered 
and  amended.  Also  to  knowe  by  certayne  sygnes  and  tokens 
whether  the  woman  be  conceaved  or  no,  and  whether  the  con- 
ception be  male  or  female,  and  finally  certayne  remedies  and 
medicines  to  farther  and  help  conception :  and  there  after  we 
wyll  (accordynge  to  our  promyse  in  the  prologue)  set  forth 
certayne  bellyfying  receptes,  and  so  make  an  ende  of  this  hole 
treatyse." 

The  second  chapter  gives  the  author's  views  as  to  the 
necessary  conditions  for  the  growing  of  corn  between  which 
and  human  generation  he  draws  a  parallel :  "  Ther  be  in  al  maner 
of  generation  thre  principal  partes  concurrent  to  the  same :  ye 
sower,  the  sede  so  wen,  and  the  receptacle  or  place  receaving 
and  contayninge  the  seede."  The  third  chapter  applies  this 
principle  to  the  consideration  of  the  causes  of  sterility,  and 
enumerates  faults  in  the  mother  receiving  the  seed,  faults  in 
the  sower,  and  faults  in  the  seed  itself.     The  mother's  womb 


BY   DR   J.    W.    BALLANTYNE.  287 

is  fancifully  compared  to  the  ground ;  it  may  be  too  hot,  too 
cold,  too  moist,  or  too  dense.  The  following  paragraph  may  be 
quoted  to  show  how  the  author  persuades  himself  that  coldness 
of  the  matrix  is  a  cause  of  sterility :  "  Tor  yf  corne  be  sowen  in 
over  cold  places,  soch  as  be  in  the  partes  of  a  countrey,  called 
Sithia,  and  in  certayne  places  of  Almayne,  or  in  soch  places 
where  is  contynual  snow  or  frost,  or  wher  the  sunne  doth  not 
shyne:  in  these  places  the  sede  or  grayn  sowen,  wyl  never 
come  to  profe,  nor  fructyfy,  but  through  the  vehement  coldnesse 
of  the  place  in  the  which  it  is  conceaved,  the  lyfe  and  quickenes 
of  the  grayne  is  utterlye  destroyed  and  adnihilat."  The  man's 
seed  also  may  be  defective  as  to  heat,  cold,  thickness,  etc. 
Even  more  fanciful  is  the  fourth  chapter,  which  pretends  to 
give  ways  of  finding  out  whether  sterility  is  due  to  defect  in 
the  woman  or  the  man.  "Let  eche  of  theim  take  of  wheate 
and  barleye  cornes,  and  of  beanes  of  ech  vii.,  the  which  they 
shal  sufFre  to  be  steped  in  theyre  severall  uryne :  the  space  of 
xxiiii.  hourses :  then  take  ii.  pottes,  soch  as  they  set  gylyflowres 
in :  fyl  them  wyth  good  earth :  and  in  the  one  let  be  set  the 
wheat,  barlye,  and  beanes,  styped  (steeped)  in  the  mans  water, 
and  in  the  other  the  wheat,  barly,  and  beanes  styped  in  the 
womans  water:  and  everye  morninge  the  space  of  viii.  or  x. 
dayes,  let  eche  of  them  with  theyr  proper  urine  water  the  sayd 
sedes  sowen  in  the  foresayd  pottes  and  mark  whose  pot  doth 
prove,  and  the  sedes  therein  contayned  doth  grow,  in  ye  partye 
is  not  the  lack  of  conception,  and  se  yf  ther  come  no  other 
water  or  rayne  on  the  pottes."  This  marvellous  test  ends  with 
the  wise  remark,  "but  trust  not  moch  this  farfet1  experiment." 
Other  tokens  are  given,  taken  from  the  works  of  Hippocrates 
(which  are  often  quoted  in  this  Book),  but  the  writer  warns  the 
reader  that  "these  tokens,  although  they  have  a  certain  reason 
and  apparence,  yet  be  they  not  alwayes  unfallyble,  but  onely 
lycklye"     The   signs   of   pregnancy  are   described   (menstrual 

1  Farfet,  far-fetched. 


288  THE   "BYKTH   OF  MANKYNDE," 

suppression,  changes  in  the  breasts,  "  longings,"  and  thickness 
of  the  urine),  and  directions  are  given  to  enable  the  midwife  to 
tell  whether  the  unborn  child  is  male  or  female. 

The  fifth  chapter  contains  various  prescriptions  supposed  to 
be  efficacious  in  curing  sterility,  but  they  call  for  little  comment 
and  no  commendation,  being  founded  upon  the  etiological 
theory  of  lack  of  heat  or  cold  or  moisture  in  the  woman  or  in 
her  uterus. 

The  sixth  and  last  chapter  of  the  Fourth  Book  may  be  called 
the  "  cosmetic  "  one,  for  it  deals  with  what  the  writer  (Eaynalde) 
calls  "  dy vers  bellyf ying "  medicines  and  remedies.  It  is  pro- 
posed to  show  how  certain  blemishes  ("  as  it  were  weedes  of  the 
body")  are  to  be  removed,  such  as  "dandraffe"  of  the  head, 
"  hayre  in  places  where  it  is  unsemelye,"  "  frekens  or  other 
spottes  in  the  face,"  warts,  and  "pymples."  There  are  also 
instructions  how  to  keep  and  preserve  the  teeth  clean,  and  how 
to  prevent  "  stynckynge  breath "  and  "  ranke  savour  of  the 
armeholes."  I  need  only  quote  the  last  paragraph:  "Item, 
auctors  do  wryte  the  ye  rootes  of  artichauts  (ye  pithe  pyked 
oute)  soden  in  whyte  wyne  and  so  dronke,  doth  dense  the 
stenche  of  the  arme  holes  and  other  partes  of  the  body  by  the 
wyne :  for  (as  Gallen  also  doeth  testyfye)  he  provoketh  copy 
and  plenty  of  stinkynge  and  unsavery  uryne,  from  all  partes  of 
the  body,  the  whych  propertye  it  hath  by  specyall  gyft  and  not 
only  by  his  hote  qualyte.  And  thus  here  I  make  an  ende  of 
thys  fourth  and  last  boke." 

The  sixth  chapter  is  wanting  in  the  Jonas  edition  of  1540, 
but  is  to  be  found  in  all  the  Eaynalde  editions  from  that  of 
1545  onwards. 

No  part  of  the  Fourth  Book  is  to  be  found  in  either  of  the 
editions  of  Eosslin's  Be  Partu  Hominis,  and  we  must  conclude 
that  Chapters  I.  to  V.  were  written  by  Jonas,  Eaynalde  adding 
the  sixth.  Both  Eaynalde  and  Jonas  seem  to  have  gone  to 
Hippocrates  for  their  facts  (if  facts  they  can  be  called),  or!  to 


BY  DR   J.   W.    BALLANTYNE.  289 

some  work  which  quotes  Hippocrates.     The  latter  is  the  more 
probable  explanation  of  the  source  of  the  Fourth  Book. 


Ehodion's  "De  Partu  Hominis." 

As  we  have  seen,  Jonas  translated  Eosslin's  or  Ehodion's 
De  Partu  Hominis  into  English,  adding  a  few  chapters  thereto, 
and  Eaynalde  revised  the  translation  and  added  new  material. 
But  who  was  Eosslin  and  what  was  the  history  of  his  work  ? 

Eucharius  Eosslin,  Eoslin,  or  Ehodian  was  a  medical  man 

practising   first   in   "Worms   and   then   in    Frankfort-on-Main. 

The  date  of  his  birth  is  unknown,  and  for  his  death  year  two 

dates  have  been  given — 1526  and  1553.     The  earlier  of  the  two 

is  most  probably  the  correct  one,  the  later  date  being  that  of 

the  death  of  his  son.     He  published  his  work   entitled   Der 

Swangern   Frawen  und    Hebammen    Rosegarten    (by   Imperial 

Privilege)  in  1513,  and  so  gave  to  the  world  the  first  separate 

work  on  midwifery.     It  was  dedicated  to  Catherine,  Princess 

of  Saxony  and  Duchess  of  Brunswick  and  Luneburg;  and  it 

was   a   compilation   from   the   works   of    Hippocrates,   Galen, 

Avicenna,  Albertus  Magnus,  Aetius,  Gordon,  and  Savonarola. 

The  earliest  edition  (that  of  1513)  had  the  same  Birth  Figures 

as  were  found  in  Jonas  and  Eaynalde ;  they  were  printed  from 

woodblocks.      The   work   was    divided    into    twelve   chapters 

corresponding  to  the  First   and  Second  Books  of   the  Jonas 

edition  of  the  Byrth  of  Mankynde,.  and  (speaking  generally)  to 

the  Second  and  Third  Books  of  the  Eaynalde  editions  of  the 

same    work.      Several    German    editions    of    the    Rosegarten 

appeared  (in  1522,  1529,  1571);   then  it  was  translated  into 

Latin,  and,  as  De  Partu  Hominis,  editions  were  brought  out  in 

1532,  1535,  1536,  1537,  1538,  1551,  1554,  1556,  and  1563 ; 

Dutch  translations,  under  the  title  of  Den  Rosegaert  van  den 

bevruchten  Vrouwen,  came  out  in  1540,  1555,  1670,  1685,  1701, 

and   1730;  and   there  were  French  versions  in   1536,    1540, 

T 


290 


THE  u  BYKTH  OF  MANKYNDE," 


1563,  and  1577.     The  English   translations  we  have   already 
described. 

In  order  that  the  reader  may  judge  of  the  accuracy  of  the 
Jonas  and  Kaynalde  rendering  of  Ehodion's  work,  I  place 
here  in  parallel  columns  the  Latin  and  the  English  of  two 
passages,  one  referring  to  the  "  Woman's  Stoole  "  and  the  other 
to  Cesarean  section : — 


From  Ehodion's  "De  Partu 
Hominis." 


From  Raynalde's  "Byrth  of 
Mankynde." 


"  Ad  quam  quidem  rem,  in  qui- 
busdam  regionibus  ut  in  Gallia  et 
Germania  superiori,  obstetrices 
peculiaria  sedilia  habent,  quae  et 
ab  humo  non  non  alte  distant,  et 
excavata  ita  sunt,  ut  facile,  quae 
debent,  transmittant,  et  reclinan- 
tem  tergo  accipiant :  quarum  forma, 
fere  est  talis,  qualem  hie  adpinxi- 
mus." 


"  At  vero  si  diverso  modo  pariens 
emoriatur  inter  enitendum,  id  quod 
signis,  quae  morientes  de  se  prae- 
bent,  facile  deprehendi  potest,  et 
partus  in  utero  superstes,  spem 
vitae  ostendat,  principio  convenit 
morientis  os,  et  infra  genitalia  cum 
matrice  aperta  et  reclusa  servare, 
quo  per  ea  et  vitalem  spiritum 
partus  capere,  et  anhelitum  recipro- 
care  possit,  id  quod  mulieres  medio- 
criter  peritae  satis  norunt.  Deinde 
reclinatae  latus  sinistrum  recto 
vulnere    novacula    incidi    atque 


"  For  the  which  purpose  in  some 
regions  (as  in  Fraunce  and  Ger- 
many) the  Midwyfes  have  stoles  for 
the  nonce,  whiche  beynge  but  lowe, 
and  not  hye  -from  the  grounde,  be 
made  so  compasse  wyse  and  cave 
or  holowe  in  the  middes,  that  that 
mai  be  receaved  from  underneth 
which  is  looked  for,  and  the  backe 
of  the  stole  leaning  backeward, 
receaveth  the  back  of  the  woman, 
the  fashion  of  the  which  stole,  is 
set  in  the  beginning  of  the  birth 
figures  hereafter." 

"  But  contrary  to  all  this,  yf  it 
chance  that  the  woman  in  her 
labour  dye,  and  the  chylde  havyng 
lyfe  in  it :  then  shal  it  be  meete 
to  kepe  open  the  womans  mouth, 
and  also  the  nether  places  ;  so  that 
the  chylde  may  by  that  means 
both  receave  and  also  expell  ayre 
and  breath,  which  otherwyse 
myght  be  stopped,  to  the  destruc- 
tion of  the  chylde.  And  then  to 
turne  her  on  the  lefte  syde,  and 
there  to  cut  her  open,  and  so  to 
take  out  the  chylde.    They  that 


BY  DR  J.    W.   BALLANTYNE.  291 

aperiri  (nam  dexterum  latus  non      be  borne  after   this    fashion  are 
ita  liberum,  propter  hepar   quod      called  Cesares,  for  because  they  be 
in  eo  situm  habet,  ingressum  in-      cutte  out  of  theyr  mothers  belly : 
cidenti  praebet)    et    inde    partus      whereupon  also  the  noble  Romayne 
inserta   manu    per    vulnus  eximi      Cesar  the  fyrste  toke  his  name." 
atque  educi  debet.     Quo  pacto  qui 
nascuntur,  cesares  dici  solent,  ut 
etiam  Romae    ille    a    quo  primo 
cesarum    familia    nomen    adepta 
fuit,   primusque    caesar,  eo  quod 
caesa  est  matre  natus,  appellatus, 
est." 

It  will  be  seen  that  the  translation  is  not  strictly  literal, 
neither  is  it  exact :  for  instance,  the  reason  why  the  abdomen 
(in  Cesarean  section)  is  to  be  opened  on  the  left  side  rather  than 
on  the  right  is  given  in  the  Latin  version  but  does  not  appear 
in  the  English.  Possibly  some  divergences  may  be  explained 
on  the  supposition  that  Jonas  and  Raynalde  used  editions  of 
Be  Partu  Hominis  which  I  have  not  been  able  to  see. 

I  have  now  concluded  my  survey  of  this  remarkable  book — 
The  Byrth  of  Mankynde — both  as  regards  its  contents  and  in 
respect  to  its  authors  and  editions.  Although  its  precepts  may 
bring  a  smile  to  the  face  of  the  obstetrician  of  the  present  day 
and  merit  his  contempt,  yet  it  was  the  most  potent  factor  in 
establishing  the  popular  customs  which  cluster  round  the 
practice  of  midwifery  in  these  Islands,  customs  which  can  be 
traced  and  recognised  even  now. 

Addenda  et  Corrigenda. 

Since  I  wrote  my  article  on  the  Author  and  Editions  of  the 
Byrlh  of  Mankynde  I  have  been  informed  of  several  other  copies 
of  some  of  the  editions,  and  have  been  led  to  alter  some  of  the 
statements  made.  For  instance,  I  am  doubtful  of  the  existence 
of  an  edition  of  1676.     Dr  C.  Napean  Longridge,  to  whom  I  am 


292  THE  "BYRTH  OF  MANKYNDE,"  - 

greatly  indebted  for  a  series  of  researches  made  for  me  in  the 
British  Museum,  finds  that  the  so-called  copy  of  1676  named  in 
the  catalogue  of  the  Museum  is  really  that  of  1626.  I  have, 
therefore,  removed  this  edition  from  the  list. 

I  have  now  had  an  opportunity  of  examining  a  copy  of  the 
1604  edition.  It  belongs  to  Prof.  H.  E.  Spencer,  to  whose  kind- 
ness I  am  indebted  for  the  privilege  of  inspecting  it.  It  is  very 
similar  in  all  respects  to  the  edition  of  1598.  The  ornamental 
title  page  is  exactly  the  same,  with  the  exception  of  a  few 
differences  in  the  typography  of  the  title.  At  the  foot  of  the 
inscription  is,  "  Imprinted  at  London  for  Thomas  Adams," 
instead  of,  "Imprinted  at  London  by  Eicharde  Watkins," 
which  appears  in  the  1598  edition.  The  colophon  reads, 
"Imprinted  at  London  for  Thomas  Adams,  1604."  There 
are  204  pages  in  this  edition,  and  three  preliminary  leaves ; 
the  plates  are  the  same,  although  two  plates  of  the  "  Byrthe 
Fygures"  happen  to  be  missing  in  the  copy  which  I  am 
describing;  and  .the  type  is  black  letter  mostly.  It  would 
seem,  therefore,  as  if  Watkins,  the  printer  of  the  1598  edition, 
had  assigned  the  blocks  as  well  as  the  license  for  printing  the 
Byrth  of  Mankynde  to  Thomas  Adams. 

I  must  correct  the  statement  made  by  me  on  p.  243  of 
my  former  article  (loc.  cit.)  about  the  ninth  figure  of  the 
Anatomical  Plates.  It  does  not  make  its  first  appearance  in 
the  edition  of  1560 ;  it  was  present  (as  Figure  5)  in  the  1545 
and  1552  editions.  The  altering  of  the  order  of  description  of 
the  figures  in  the  1560  issue  had  misled  me. 

Here  follows  the  revised  list  of  the  editions.  I  may  take 
this  opportunity  of  thanking  Dr  E.  Wilson  Gibson,  of  Orton, 
Tebay,  Westmorland,  for  kindly  giving  me  a  perfect  copy  of 
the  1654  edition. 


BY  DR  J.   W.   BALLANTYNB.  293 

Summary  of  the  Editions  of  the  "  Byrth  of  Marikynde." 

Edition   of    1540.     Jonas's    Translation    of    Eosslin.     British 

Museum. 
Edition  of   1545.     Eaynalde's   Translation.     British  Museum ; 

Royal  College  of  Physicians,  London ;  Hunterian  Library, 

University,  Glasgow. 
Edition   of   1552.     Eaynalde's   Translation.     Eoyal  College  of 

Physicians,  Edinburgh;   London   Obstetrical   Society;  Dr 

W.  Blair  Bell,  Liverpool. 
Edition   of   1560.     Eaynalde's   Translation.     Eoyal  College  of 

Surgeons,   London;    Dr    J.    W.    Ballantyne,   Edinburgh; 

University  of  Aberdeen. 
Edition  of    1565.     Eaynalde's   Translation.     British  Museum; 

University  of  Edinburgh;  Eoyal  College  of  Surgeons  of 

London;      Washington      Library;      Hunterian     Library, 

University,  Glasgow. 
Edition  of  1564  (?).    Eaynalde's  Translation.    British  Museum ; 

University   of    Glasgow;    Eoyal    College    of    Physicians, 

London ;  Dr  J.  F.  Payne,  London. 
Edition  of  1593  (?).     Eaynalde's  Translation.    Eadford  Library, 

Manchester. 
Edition   of   1598.     Eaynalde's  Translation.     British  Museum; 

Eoyal      Medico  -  Chirurgical     Society     of     London ;     Dr 

C.    E.     Underhill;      Washington     Library;      Hunterian 

Library,  University,  Glasgow;  Medical  Institution,  Liver- 
pool. 
Edition  of    1604.     Eaynalde's   Translation.     British  Museum; 

Washington  Library ;  Dr  H.  E.  Spencer,  London. 
Edition   of   1613.     Eaynalde's   Translation.     Eoyal  College  of 

Surgeons  of  London  (2  copies). 
Edition  of  1626.     Eaynalde's  Translation.     British   Museum; 

University   of    Edinburgh;    London   Obstetrical   Society; 

Faculty  of  Physicians  and  Surgeons  of  Glasgow. 


294      THE  "BYRTH   OF  MANKYNDE,"    BY   DR  J.    W.    BALLANTYNE. 

Edition  of  1634.  Kaynalde's  Translation.  British  Museum; 
Koyal  College  of  Physicians,  London;  London  Obstetrical 
Society ;  Washington  Library. 

Edition  of  1654.  Kaynalde's  Translation.  British  Museum; 
Washington  Library ;  Dr  W.  L.  Eeid,  Glasgow ;  Uni- 
versity of  Aberdeen ;  Dr  J.  W.  Ballantyne,  Edinburgh. 


INDEX 


Abortion,  case  of  repeated,  due  to 
syphilis;  treatment  by  potassium 
iodide;  birth  of  child  with  con- 
genital goitre  (Watson),  204. 

Albuminuria,  acute,  caused  by  pres- 
sure of  tumour  on  both  ureters 
(Porter).  75. 


B 


Ballantyne,  Dr  J.  W.,  gives  inaugural 
address,  3 ;  reads  paper,  236 ;  shows 
specimens,  120,  191,  221  •  on  Dr 
Porter's  paper,  81  ;  on  Dr  Eliz. 
Macdonald's  paper,  116;  on  Dr 
Haultain's  paper,  131 ;  on  Sir 
Halliday  Croom's  paper,  158;  on 
Professor  Jardine's  paper,  1 83 ;  on 
Dr  Campbell's  paper,  189;  on  Dr 
Brewis's  paper,  203 ;  on  Dr  Watson's 
paper,  218;  on  Professor  Kynoch's 
paper,  234. 

Barbour,  Dr  Freeland,  moves  vote  of 
thanks,  2;  reads  paper,  136 ;  shows 
specimens,  121  ;  on  Dr  Lackie's 
paper,  33  ;  on  Dr  Haultain's  paper, 
132  ;  on  Sir  Halliday  Croom's  paper, 
158;  on  Professor  Kynoch's  paper, 
230. 

Bilateral  ovarian  dermoid  tumours 
complicating  pregnancy  (Campbell), 
184. 

Brewis,  Dr  N.  T.,  reads  papers,  49, 
191 ;  shows  specimens,  41,  140,  189  ; 

295 


on  Dr  Ferguson's  paper,  65  ;  on  Dr 
Haultain's  paper,  133;  on  Sir 
Halliday  Croom's  paper,  1 59 ;  replies 
to  discussion,  57,  203. 
"Byrth  of  Mankynde";  its  contents 
(Ballantyne),  236. 


Cesarean  section  for  contracted  pelvis, 
series  of  five  cases  of  (Kynoch),  221. 

Campbell,  Dr  Malcolm,  reads  paper, 
184;  replies  to  discussion,  189. 

Cervical  fibroids  removed  by  ab- 
dominal hysterectomy,  a  clinical 
and  anatomical  study  of  thirty 
cases  of  (Haultain),  121. 

Church,  Dr,  on  Dr  Lackie's  paper,  37  ; 
on  Sir  Halliday  Croom's  paper,  162. 

Croom,  Professor  Sir  Halliday,  reads 
paper,  143;  replies  to  discussion, 
162. 


I) 


Dermoid  tumours,  bilateral  ovarian 

(Campbell),  184. 
Dewar,  Dr,  on  Dr  Lackie's  paper,  35. 

E 

Epilepsy  and  the  status  epilepticus  in 
connection  with  pregnancy  and 
labour  (Jardine),  165. 


296 


INDEX. 


Exophthalmic  goitre  in  its  relation  to 
Obstetrics  and  Gynaecology  (Groom), 
143. 


Fellows,  election  of,  Ordinary,  2,  41, 
74,  120,  163  j  Honorary,  220. 

Ferguson,  Dr  Haig,  reads  paper,  57 ; 
shows  specimens,  45,  142,  163,  190; 
on  Dr  Lackie's  paper,  34 ;  on  Dr 
Leary's  paper,  74;  on  Professor 
Jardine's  paper,  182;  on  Dr  Wat- 
son's paper,  217;  replies  to  discus- 
sion, 66. 

Fibroid  tumours,  complicating  preg- 
nancy, treated  by  hysterectomy 
(Brewis),  49. 

Fibroid  tumours  in  pregnancy,  hys- 
terectomy for  (Barbour),  136 

Fordyce,  Dr  W.,  shows  specimens,  164. 

Future  of  Obstetrics,  inaugural 
address  on  the  (Ballantyne),  3. 


G 


Goitre,  congenital,  birth  of  child  with, 
in  case  of  repeated  abortion,  treated 
by  potassium  iodide  (Watson),  204. 

Goitre,  exophthalmic,  in  its  relation 
to  Obstetrics  and  Gynaecology 
(Croom),  143. 


Haultain,  Dr,  reads  paper,  121  ;  shows 
specimens,  48,  74,  164;  on  Dr 
Porter's  paper,  81 ;  on  Dr  Eliz. 
Macdonald's  paper,  117;  on  Pro- 
fessor Jardine's  paper,  180;  on  Dr 
Campbell's  paper,  188. 


Intractable  uterine  haemorrhage  and 
arteriosclerosis  of  uterine  vessels 
(Eliz.  Macdonald),  83. 


Jardine,  Professor,  reads  paper,  165; 
replies  to  discussion,  183, 


Kerr,  Dr  Munro,  on  Professor  Kynoch's 
paper,  230. 

Kynoch,  Professor,  reads  paper,  221  ; 
shows  specimens,  220 ;  on  Dr 
Porter's  paper,  82 ;  replies  to  dis- 
cussion, 235. 


Lackie,  Dr  Lamond,  reads  paper,  28  ; 
on  Dr  Brewis's  paper,  56  ;  on  Dr 
Leary's  paper,  73 ;  on  Professor 
Kynoch's  paper,  234 ;  replies  to 
discussion,  40. 

Leary,  Dr  Garnet,  reads  paper,  67. 


M 


Macdonald,  Dr  Eliz.,  reads  paper,  83  ; 
replies  to  discussion,  119. 


N 


Nicholson,  Dr  Oliphant,  on  Dr 
Lackie's  paper,  37  ;  on  Sir  Halliday 
Croom's  paper,  160 ;  on  Dr  Watsons 
paper,  214. 


O 


Occipito-posterior  cases,  the  manage- 
ment of  some  difficult  (Lackie),  28. 
Office-bearers,  election  of,  2. 


Paterson,  Dr  Keppie,  on  Dr  Brewis's 
paper,  57  ;  on  Dr  Leary's  paper,  72  ; 
on  Dr  Watson's  paper,  216. 

Porter,  Dr  Fred.,  reads  paper,  75  ;  on 
Dr  Ferguson's  paper,  66;  on  Dr 
Eliz.  Macdonald's  paper,  119;  on 
Professor  Jardine's  paper,  183; 
replies  to  discussion,  82. 

Prognosis  of  pregnancy  in  patients 
with  one  kidney,  on  the ;  with 
notes  of  an  unusually  complicated 
case  of  labour  after  nephrectomy 
(Haig  Ferguson),  57, 


INDEX. 


297 


Puerperal  septicaemia,  successful  treat- 
ment of,  by  antistreptococcic  serum 
(Leary),  67. 


R 


Kitchie,  Dr  James,  moves  vote  of 
thanks,  34 -shows  specimens,  48; 
on  Dr  Lackie's  paper,  34 ;  on  Dr 
Brewis's  paper,  56;  on  Dr  Fergu- 
son's paper,  66 ;  on  Dr  Porter's 
paper,  82 ;  on  Dr  Eliz.  Macdonald's 
paper,  1 1 8  ;  on  Sir  Halliday  Croom's 
paper,  159  ;  on  Dr  Watson's  paper, 
214 ;  on  Professor  Kynoch's  paper, 
234. 


Specimens,  exhibition  of,  41,  74,  120, 
140,  163,  189,  220. 


Simpson,  Dr  Barbour,  shows  medal, 

48. 


Treasurer,  annual  statement  of,  1. 


Vaginal  Caesarean  section,  six  cases 
of  (Brewis),  191. 


W 


Watson,  Dr  B.  P.,  reads  paper,  204 
on  Dr  Eliz.  Macdonald's  paper,  119 
on  Sir  Halliday  Croom's  paper,  162 
replies  to  discussion,  219. 


PR1NTKD   BY 

OLIVER    AND    BOYD, 

EDINBURGH 


SERlM- 


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v.  32 


Edinburgh  Obstetrical  Society 
Transactions 


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